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Therapeutics: 

ITS 


PRINCIPLES AND PRACTICE. 


/ BY 

H. C. WOOD, M.D, LL.D., 

'\ 

PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS, AND CLINICAL PROFESSOR OF DISEASES OF 
THE NERVOUS SYSTEM, IN THE UNIVERSITY OF PENNSYLVANIA. 


A WORK ON MEDICAL AGENCIES, DRUGS AND POISONS, 
WITH ESPECIAL REFERENCE TO THE RELA¬ 
TIONS BETWEEN PHYSIOLOGY AND 
CLINICAL MEDICINE. 





THE SEVENTH EDITION OF 

A TREATISE ON THERAPEUTICS, 

REARRANGED , REWRITTEN , AND ENLARGED. 


/ 


PHILADELPHIA: 



J. B. LIPPINCOTT COMPANY. 

LONDON: 10 HENRIETTA STREET. 





































PREFACE TO THE SEVENTH EDITION. 


The speedy exhaustion of successive editions of this treatise upon 
therapeutics has not only stimulated its author to render it worthy of 
the kind judgment and continued favor of his co-laborers, but has also 
made it possible for him at short intervals to incorporate in it the 
recent researches in what is probably the most active branch of medi¬ 
cal science. Comparatively few persons have a full conception of the 
rapid progress of therapeutics and of the amount of labor involved in 
keeping up with this forward movement. Scarcely three years have 
elapsed since the appearance of the sixth edition, yet the preparation 
of the present volume has necessitated a careful study by its author 
of nearly six hundred memoirs. There has been during the last decade 
a special growth in the appreciation by the medical profession of the 
value of remedial measures other than the administration of drugs. 
In preceding editions of this book the demand for this sort of knowl¬ 
edge was in part met by a discussion of the application of the various 
forces of nature to the relief of human ailments. In the present vol¬ 
ume this formerly second portion of the book has been made the first, 
and its scope has been much extended, so as to take into considera¬ 
tion, besides various miscellaneous remedial measures, massage, metallo- 
therapy, the feeding of the sick, and the dietetic and general treat¬ 
ment of underlying bodily constitutional states or diatheses, such as 
exhaustion, obesity, and lithiasis. The portion of the work devoted to 
the study of drugs has been entirely rearranged, in accordance with 
a new classification, which it is hoped will commend itself to the reader 
as natural, and therefore as more simple than the one previously em¬ 
ployed. All the new drugs, such as hydrastin, strophanthus, sparteine, 
adonidine, iodol, ichthyol, paraldehyde, urethan, hypnone, amylene 
hydrate, methylal, oil of sandal-wood, kawa, extract of malt, papain, 
antifebrin, salol, bethol, thallin, kairin, acetphenetidin, lanolin, saccharin, 

sulphuretted hydrogen, etc., have been carefully considered, while many 

6 



6 


PREFACE TO THE SEVENTH EDITION. 


articles upon older drugs, such as cocaine, antifebrin, and caffeine, have 
been completely rewritten: further, the discussions of even the longest 
and best known members of the Materia Medica list have been care¬ 
fully gone over, and, whenever it has been to the author possible, have 
been made clearer and more practical. Thus, notwithstanding the 
constant effort at condensation, nearly two hundred pages of new 
matter have been added to the book. By the use of italics, or, in 
some articles, by giving a summary in a distinct paragraph, the at¬ 
tempt has been made to point out to the student what is essential in 
our knowledge of the physiological action of drugs. In no previous 
edition have the amount of change and the thoroughness of revision 
been so great, and the author believes that as a guide to the treatment 
of disease the book is much superior to its former self. 


PREFACE TO THE FIRST EDITION. 


At the present time, when the shelves of private and public libra¬ 
ries are groaning beneath their ever-increasing loads, when a thousand 
presses in every city send forth day and night their printed messages 
until the earth is filled with them, it seems almost presumptuous for 
any one to offer new volumes to the world. Indeed, art is so long, life 
is so short, that every student has the right to demand of an author by 
what authority he doeth these things, and to challenge every memoir 
for its raison d'etre. This being so, it assuredly will not appear egotistical 
for the author to state that his voluntary task was first suggested by 
his own wants, and that to its performance he has brought the training, 
labor, and experience of years spent in the laboratory, the study, the 
class-room, and the hospital ward. 

There are a number of excellent treatises upon materia medica and 
therapeutics; yet in various attempts at original research, as well as in 
the ward and the lecture-room of the hospital, I have keenly felt the 
want of something more. There are many points of view from which 
a subject can be looked at; there are many paths by which it may be 
approached; and to me, other points of view, other modes of approach, 
have been far more enticing than those adopted in our standard treatises. 

The old and tried method in therapeutics is that of empiricism, or, 
if the term sounds harsh, of clinical experience. As stated by one of 
its most ardent supporters, the best possible development of this plan 
of investigation is to be found in a close and careful analysis of cases 
before and after the administration of a remedy, and, if the results be 
favorable, the continued use of the drug in similar cases. It is evident 
that this is not a new path, but a highway already worn with the eager 
but weary feet of the profession for two thousand years. 

That very much has been thus accomplished it were folly to deny. 
Leaving out of sight the growth of the last two decades, almost all of 
the current therapeutic knowledge has been gained in this way. 

Therapeutics developed in this manner cannot, however, rest upon 
a secure foundation. What to-day is believed is to-morrow to be cast 
aside, certainly has been the law of advancement, and seemingly must 
continue to be so. What has clinical therapeutics established perma¬ 
nently and indisputably ? Scarcely anything beyond the primary facts 

7 



8 


PREFACE TO THE FIRST EDITION: 


that quijiia will arrest an intermittent, that salts will purge, and that 
opium will quiet pain and lull to sleep. 

To established therapeutic facts the profession clings as with the 
heart and hand of one man,—clings with a desperation and unanimity 
whose intensity is the measure of the unsatisfied desire for something 
fixed. Yet with what a Babel of discordant voices does it celebrate 
its two thousand years of experience ! 

This is so well known that it seems superfluous to cite examples 
of the therapeutic discord; and one only shall be mentioned, namely, 
rheumatism. In this disease, bleeding, nitrate of potassium, quinine, 
mercurials, flying blisters, purgation, opium, the bromides, veratria, 
and a host of other remedies, all have their advocates clamorous for 
a hearing; and above all the tumult are to be heard the trumpet- 
tones of a Chambers, “ Wrap your patients in blankets and let them 
alone.” 

Experience is said to be the mother of wisdom. Yerily she has 
been in medicine rather a blind leader of the blind; and the history of 
medical progress is a history of men groping in the darkness, finding 
seeming gems of truth one after another, only in a few minutes to cast 
each back to the vast heap of forgotten baubles that in their day had 
also been mistaken for verities. In the past, there is scarcely a con¬ 
ceivable absurdity that men have not tested by experience and for a 
time found to be the thing desired; in the present, homoeopathy and 
other similar delusions are eagerly embraced and honestly believed in 
by men who rest their faith upon experience. 

Harrowing our gaze to the regular profession and to a few decades, 
what do we see ? Experience teaching that not to bleed a man suf¬ 
fering from pneumonia is to consign him to an unopened gi’ave, and 
experience teaching that to bleed a man suffering from pneumonia is 
to consign him to a grave never opened by nature. Looking at the 
revolutions and contradictions of the past,—listening to the therapeutic 
Babel of the present,—is it a wonder that men should take refuge in 
nihilism, and, like the lotos-eaters, dream that all alike is folly,—that 
rest and quiet and calm are the only human fruition ? 

Since the profession has toiled so long and found so little, if further 
progress is to be made we must question the old methods and search 
out new ones, which haply may lead to more fruitful fields. In the 
ordinary affairs and business of life, when anything is to be accom¬ 
plished, the effort always is to discover what is to be done, and then 
what are the means at command. A primary knowledge of the end 
to be accomplished, and a secondary acquaintance with the instruments, 
are a necessity for successful human effort; and until the sway of this 
law is acknowledged by physicians, medicine can never rise from the 
position of an empirical art to the dignity of applied science. Until 
within a comparatively recent period, it has been impossible to comply 
with this law. But, through the advances made by the pathologists 


PREFACE TO THE FIRST EDITION. 


9 


and by the students of the natural history of disease, we are fast 
learning the methods in which nature brings the body back to health. 
When this is done,—when disease is thoroughly understood,—we shall 
have wi'ought out the first element of the problem, shall have com¬ 
plied with the first requirement of the law. 

It is scarcely within the province of the therapeutist, and certainly 
is not possible within the scope and limits of this work, to discuss at 
length the natural history of disease; but it is allowable to point out 
evident indications for relief; and this I have done to a greater or less 
extent throughout the book. 

The work of the therapeutist is chiefly with the second portion of 
the law. Evidently, it is his especial province to find out what are the 
means at command, what the individual drugs in use do when put into 
a human system. It is seemingly self-evident that the physiological 
action of a remedy can never be made out by a study of its use in 
disease. Under all circumstances, the problem is one of the most 
complex with which the human mind has to grapple; and to introduce 
into this problem the new and ever-varying factors of the effect of 
disease and its natural vibrations on the system is to put the matter 
beyond human prescience. 

In spite, then, of Dr. Niemeyer’s assertion that experiments made 
with medicaments upon the lower animals or upon healthy human 
beings have, as yet, been of no direct service to our means of treating 
disease, and that a continuation of such experiments gives no prospect 
of such service, it is certain that in these experiments is the only 
rational scientific groundwork for the treatment of disease. We must 
discover what influence a drug exerts when put into the body of a 
patient before we can use it rationally; and we can gain this coveted 
knowledge only in the method indicated. 

It has been strenuously objected, especially to experiments upon 
animals, that drugs do not act upon the lower creatures in the same 
manner as they do upon man. When I first commenced the studies 
whose outcome is the present volume, I was profoundly impressed with 
the truth of this oft-repeated assertion and with the difficulties which 
it put in the way. To-day I do not believe that, stated in its broad 
sense, it is true. Indeed, more strongly, I assert that it is not true; 
that, in the vast majority of cases, the actions of drugs upon man and 
upon the lower animals are, though seemingly different, in reality 
similar; that the more knowledge we acquire, the fewer exceptions 
remain unexplained; and that the whole matter is in all probability 
subject to laws whose development will greatly aid in our explanation 
of various obscure clinical phenomena. 

The general proofs of these assertions are sufficiently obvious, I 
think, in the following pages to render it unnecessary for me to dwell 
upon them at length here: moreover, if they be not so obvious to 
others as to myself, space is here wanting for a full discussion of the 


10 


PREFACE TO TEE FIRST EDITION. 


subject. I can only make a few general remai’ks, and point out some 
of what I believe to be the governing laws. 

In the first place, degree and quality are distinct things, and should 
not be confounded. Yet they frequently are; and because it requires 
as much morphia to kill a pigeon of a pound weight as to destroy a 
man, we are told that medicines act differently upon man and the lower 
animals. Evidently the conclusion is a non-sequitur, and difference of 
susceptibility is no proof of difference in the mode of impression. A 
teaspoonful of Epsom salt may purge one man, while it may require 
ounces to affect another. Evidently there is a difference of suscepti¬ 
bility ; but when the impression is once made it is of the same character 
in each case. As with man and man, so with man and the pigeon,— 
susceptibility is no measure or gauge of the character of the impression. 

A large number of drugs—indeed, it may be said, the larger number 
of important drugs—exert in the system antagonistic actions. Thus, 
atropia stimulates the spinal cord, but destroys the conducting power 
of the nerve-trunks. It is evident that as one or the other of these 
influences predominates, will there be convulsions or paralysis. Now, 
if for any reason one animal be exceedingly sensitive to the spinal 
action of atropia, that animal will in belladonna-poisoning suffer from 
convulsions, while its fellow, which is affected chiefly by the nerve- 
action of the drug, will, under like circumstances, have paralysis. 
Here the mere clinician, with his superficial knowledge, seeing the 
paralyzed and the convulsed lying side by side, says, TThat a hopeless 
muddle! Poor fools, these vivisectors! they will never come to any 
good! In truth, the differences in symptoms in these and in many 
other cases simply depend upon differences in susceptibility; and the 
only lesson that the circumstance teaches is the importance of dis¬ 
covering the laws which govern these susceptibilities. 

A law which governs the susceptibility to the action of drugs is, 
that the more highly specialized any system is, the more readily affected 
is it by a medicine. Thus, the cerebrum of a man is far more highly 
organized than that of any other animal, and consequently he is far 
more sensitive to the action of drugs which affect the cerebrum than 
are the lower forms. Again, in the frog the spinal system is especially 
developed,—probably, in proportion to the cerebrum, more so than in 
any other of the animals commonly experimented with: consequently 
the batrachian is excessively sensitive to remedies which, like strychnia, 
affect the spinal cord. In obedience to this law, we have resulting the 
action of opium,—an action which has been considered the strongest 
proof of the hopelessness of any attempt to explain the effects of 
drugs upon a man by experiments upon the lower animals. In man, 
opium causes deep stupor and general relaxation; in the frog, it causes 
tetanic convulsions. The explanation of these seeming inconsistencies 
is, however, very evident when the whole subject is looked at. Opium 
in all animals has a double action, one upon the cerebrum and one upon 


PREFACE TO THE FIRST EDITION. 


11 


the spinal centres. In the frog, the latter being the more highly 
organized, the spinal action overcomes the cerebral; in man, the cere¬ 
brum being the more sensitive, stupor replaces the convulsions: yet in 
man convulsions sometimes occur in opium-poisoning, and in the frog 
the dose can be so managed as to cause stupor. 

A second law which seems to hold sway over the action of drugs 
upon different animals is that great differences of function in a system 
affect its relation to drugs: thus, in a herbivorous animal the aliment¬ 
ary canal is very different from what it is in the carnivora, whose diges¬ 
tive organs in turn differ from those of man,—the omnivore. Medi¬ 
cines which act upon the alimentary canal are apt to vary in their 
effects upon different orders of animals. 

Converse to the above law is that which renders systems which are 
little specialized similarly acted upon by drugs in different classes of 
animals. 

Thus, the general structure and the functions of the circulatory 
system are very uniform among vertebrates, as is also the action of 
those drugs which affect chiefly the circulation : thus, aconite, or digi¬ 
talis, or potash, influences in the one way the heart of the frog, of the 
rabbit, and of man. 

There are a very few apparent exceptions to the uniformity of the 
action of drugs upon all animals, which seemingly contravene the laws 
that have been mentioned. These exceptions are so few, however, that 
without doubt advancing knowledge will by and by explain them all 
and show what are the laws which for the time being hold in abeyance 
or overcome those already stated. 

An asserted fact which has recently been brought forward as re¬ 
vealing the worthlessness of animal experimentation is that some 
monkeys are not susceptible to the action of strychnia, while others 
are. Granting the truth of the asserted fact, it certainly is explainable. 
It is at least conceivable that a given species of animal may, by the 
gradually-acquired habit of feeding upon a substance containing a 
narcotic poison, acquire an insusceptibility to the influence of that 
poison which shall as it were belong to its specific type, or, in other 
words, be an acquired specific character. The nervous system of the 
opium-eater becomes accustomed to the stimulant, and it is not impos¬ 
sible that a measure of the habit should be transmitted. If the Dar¬ 
winian law of the gradual evolution by the survival of the fittest have 
any force, these curious apparent freaks of medicines in regard to their 
physiological action may be the result of this law, especially since it is 
species which are affected. It is not all monkeys that are proof against 
strychnia, but, as we are distinctly told, only one species of monkey; 
and, so far as I know, it is not all deer that are said to thrive when fed 
upon tobacco, but only the Yirginia deer. Whether this conception be 
or be not a mere fancy, this much is to my mind very clear, that the 
few scattered exceptions ought not to outweigh the immense mass of 


12 


PREFACE TO THE FIRST EDITION. 


evidence upon the other side, and that it is inconceivable that drugs, 
in their relations to animal organisms, differ from all other created 
things in not being subject to law. 

In the early portion, of this preface I stated that the work had 
grown out of a need felt by myself: that need was for a book into 
which should be gathered the many scattered facts in regard to the 
physiological action of medicine,—a book in which an attempt should 
be made to sift the true from the false, to reconcile seeming differences, 
to point out what we know and what we do not know, and to give a 
platform from which investigators might start forward without the 
necessity of being, as is so often the case, ignorant of what was already 
achieved, or of spending a great deal of time in a wild hunt through 
the almost boundless, but often scattered and inaccessible, ranges of 
Continental literature. 

The plan of the present work has been to make the physiological 
action of remedies the principal point in discussion. A thoroughly 
scientific treatise would in each article simply show what the drug 
does when put into a healthy man, and afterwards point out to what 
diseases or morbid processes such action is able to afford relief. Un¬ 
fortunately, in the great majority of cases our knowledge is not com¬ 
plete enough for this, and the clinical method has to be used to supple¬ 
ment the scientific plan. 

I have added to the book a consideration of toxicology, so far as it 
is of interest to the physician. This has been done for several reasons. 
First, it was necessary to study the action of poisonous drugs upon man, 
in order to make out their physiological action; secondly, physicians 
are constantly required to diagnosticate and to treat cases of poisoning; 
thirdly, it is often of the greatest importance for a medical man in a 
court of law to be able to state what are the symptoms and post-mortem 
appearances produced by a given poison, what diseases they simulate, 
and how far and in what they differ from the phenomena of these 
diseases. That part of the science of toxicology which treats of the 
recognition of poisons in the cadaver, or in food and drink, belongs to 
the domain of the chemist, and I have avoided it altogether. For a 
similar reason, in the sections on materia medica, the chemical relations 
of mineral substances have not been discussed at all. 


TABLE OF CONTENTS 


Introduction. 

PART I. 

REMEDIES, REMEDIAL MEASURES, AND REMEDIAL 
METHODS WHICH ARE NOT DRUGS. 

Preliminary Considerations. 

Chapter I.— General Considerations; Massage; Feeding of the Sick, including 
General Considerations, Liquid Meat Foods, Milk Foods, Artificially-Digested 
Foods; Metallo-Therapy. 

Chapter II.—The Treatment of Systemic States, including Exhaustion and Neur¬ 
asthenic Conditions, Corpulence, and Lithiasis. 

Chapter III. —Caloric: Use of Cold; Local Employment of Cold; Cold as a 
Tonic and Stimulant; Cold in Pyrexia. 

Chapter IV.— Electricity : General Considerations, including Electrical Physics 
and Physiology as applied to Human Medicine; Employment of Electricity for 
the Diagnosis, Prognosis, and Therapeusis of Motor and Sensory Affections; 
Application of Electricity to the Nerve-Centres, and Use as a Tonic. 


PART II. 

DRUGS. 

Preliminary Considerations ; Pharmacy ; Therapeutics ; Pharmacology; Prepara¬ 
tions ; Indications for the Use of Medicine; General Methods of Therapeutics, 
including Homoeopathy; Modes of Administration; Doses, and the Circum¬ 
stances that modify them ; the Art of Prescribing and Combining Medicines. 


DIVISION I-SYSTEMIC REMEDIES. 

CLASS I-GENERAL REMEDIES. 

ORDER I.—NERVINES, 

Family I. —Antispasmodics : Musk; Castor; Valerian; Asafetida; Camphor; 
Oil of Camphor; Monobromated Camphor; Carholated Camphor ; Amber and 
its Oil; Hoffman’s Anodyne; Hops ; Lactucarium ; Cimicifuga. 

Family II. —Anesthetics : Nitrous Oxide; Ether; Chloroform ; Bichloride of 
Methylene ; Bromide of Ethyl; Bromoform. 



14 


TABLE OF CONTENTS. 


Family III.— Somnifacients : Opium; Morphine; Narceine; Codeine; Narco¬ 
tine ; Thebaine; Papaverine; Laudanine; Porphyroxine; Cryptopine ; Meco- 
nine; Hydrocotarnine; Hydrobromate of Hyoscine; Hydrate of Chloral; Meta- 
chloral ; Chloral Camphor; Butyl-Chloral Hydrate; Paraldehyde; Amylene 
Hydrate; Urethan; Hypnone; Methylal. 

Family IV. —Delirifacients : Cannabis Indica ; Cannabis Americana ; Bella¬ 
donna Leaf and Belladonna Boot; Atropine; Homatropine ; Stramonium; 
Hyoscyamus ; Hyoscine; Coca; Cocaine. 

Family V.— Excito-Motors : Nux Vomica; Strychnine; Brucine; Ignatia. 
Family VI. —Depresso-Motors : Calabar Bean; Bromide of Potassium ; Bromide 
of Ammonium; Bromide of Sodium; Bromide of Lithium ; Bromide of Nickel; 
Hydrohromic Acid ; Bromal Hydrate ; Nitrite of Amyl; Nitrite of Potassium ; 
Nitrite of Sodium; Nitroglycerin; Nitrite of Ethyl; Valerianate of Amyl; 
Lobelia; Gelsemium ; Tobacco ; Conium. 

ORDER II.—CARDIANTS. 

Family I. —Cardiac Stimulants : Ammonium and its Salts ; Alcohol ; Digitalis ; 

Caffeine ; Strophanthus ; Sparteine ; Adonidine. 

Family II.— Cardiac Depressants: Antimony and its Salts ; Veratrum Viride ; 
Veratroidine and Jervine; Veratrum Album; Veratrine ; Arnica Flowers and 
Arnica Boot; Aconite; Aconitine; Hydrocyanic Acid ; Tartaric Acid; Citric 
Acid; Lemon-Juice; Acetic Acid; Vinegar; Oxalic Acid. 

ORDER III.—NUTRIANTS. 

Family I. —Astringents : Tannic Acid ; Gallic Acid ; Galls ; Catechu ; Kino ; 
Haematoxvlon; Bhatany; Oak Bark; Bed and Pale Bos6; Geranium; Bhus 
Glabra; Alum; Sulphate of Aluminium; Lead, its Salts and Preparations; 
Bismuth, its Salts and Preparations; Oxalate of Cerium; Zinc, its Salts and 
Preparations ; Copper, its Salts and Preparations ; Silver, its Salts and Prepara¬ 
tions. 

Family II. —Tonics : Iron, its Salts and Preparations ; Manganese, its Salts and 
Preparations; Sulphuric Acid ; Hydrochloric Acid ; Nitric Acid ; Nitro-Hydro- 
chloric Acid; Lactic Acid ; Phosphorus ; Phosphide of Zinc. 

Family III.— Alteratives : Arsenic and its Preparations ; Mercury, its Salts and 
Preparations ; Iodine, its Salts and Preparations ; Iodoform ; Iodol; Cod-Liver 
Oil; Phosphoric Acid; Colchicum Seed and Colchicum Boot; Sarsaparilla; 
Guaiac Wood and Guaiac Besin; Mezereum ; Sassafras ; Taraxacum; Ichthyol. 
Family IV.— Antiperiodics : Cinchona and its Alkaloids ; Warburg’s Tincture; 
Eucalyptus; Picric Acid. 

Family V. —Antipyretics : Carbolic Acid ; Creasote ; Menthol ; Thymol ; Be- 
sorcin ; Salicylic Acid ; Oil of Gaultheria ; Salicin ; Salol; Bethol; Antipyrin; 
Antifehrin ; Thallin; Kairin ; Acetphenetidin. 


CLASS n.-LOCAL REMEDIES. 

Family I.— Stomachics: Quassia; Gentian; Nectandra; Hydrastin; Berherine; 
Columbo; Thoroughwort; Chirata; Wild-Cherry Bark; Cinnamon; Cloves; 
Nutmeg; Allspice-; Cardamoms; Ginger; Black Pepper; Bed Pepper; Oil of 
Cajuput; Oil of Sassafras;- Orange Peel and Orange Flowers; Umbelliferous 
Aromatics ; Chamomile; Serpentaria; Cascarilla. 


TABLE OF CONTENTS. 


15 


Family II.— Emetics: Ipecacuanha; Bloodroot; Apomorphine; Mustard; Min¬ 
eral Emetics. 

Family III.— Cathartics: Tamarinds; Manna; Cassia Fistula; Cascara Sagrada; 
Wahoo; Magnesia; Sulphur; Sulphurated Potassa; Sulphurated Lime; Castor 
Oil; Mercurials ; Rhubarb ; Butternut; Aloes ; Senna; Sulphate of Magne¬ 
sium ; Solution of Citrate of Magnesium; Granulated Citrate of Magnesium; 
Sulphate of Sodium ; Phosphate of Sodium ; Rochelle Salt; Seidlitz Powder; 
Sulphate of Potassium; Sulphovinate of Sodium; Jalap; Colocynth; Scam- 
mony ; Compound Cathartic Pills ; May-Apple ; Elaterium ; Gamboge ; Croton 
Oil; Black Hellebore. 

Family IY.— Diuretics : Squill; Broom ; Blatta; Sweet Spirit of Nitre; Caffeine; 
Potassium and its Salts ; Lithium and its Salts ; Buchu ; Uva TTrsi; Chimaphila ; 
Juniper; Oil of Erigeron; Oil of Sandal-Wood; Stigmata of Zea Mays; 
Canada Turpentine ; White Turpentine; Oil of Turpentine ; Chian Turpentine ; 
Copaiba ; Cubebs ; Matico ; Kawa ; Cantharides. 

Family Y.— Diaphoretics: Turkish Baths and Russian Baths; Dover’s Powder; 
Jaborandi; Spirit of Mindererus ; Sweet Spirit of Nitre; Alcohol. 

Family VI. — Expectorants: Atomization; Lobelia; Ipecacuanha; Tartar 
Emetic; Grindelia; Chloride of Ammonium ; Senega; Ammoniac ; Sulphu¬ 
retted Hydrogen ; Benzoin ; Balsam of Peru; Balsam of Tolu ; Garlic; Squill; 
Tar ; Eucalyptus; Terebene. 

Family YII.— Emmenagogues : Myrrh ; Black Hellebore ; Savine; Rue; Parsley ; 
Apiol; Permanganate of Potassium ; Cantharides ; Guaiac ; Tanacetum ; Penny¬ 
royal. 

Family YIII. —Oxytocics: Ergot; Cotton-Root; Ustilago. 

Family IX. —Sialagogues : Pellitory. 

Family X.— Errhines : Cubebs. 

Family XI.— Epispastics : Cantharides. 

Family XII.— Rubefacients : Mustard ; Capsicum ; Spices ; Oil of Turpentine ; 

Ammonia; Burgundy Pitch ; Canada Pitch Plaster. 

Family XIII. —Escharotics : Caustic Potash ; Vienna Paste ; Arsenious Acid ; 
Ohloride of Zinc; Canquoin’s Paste; Corrosive Sublimate; Solution of Nitrate 
of Mercury; Sulphuric Acid; Nitric Acid; Muriatic Acid; Chromic Acid; 
Bromine ; Sulphate of Zinc ; Sulphate of Copper; Burnt Alum. 

Family XIY. —Demulcents : Gum Arabic ; Tragacanth ; Slippery Elm ; Iceland 
Moss ; Carrageen ; Liquorice Root; Flaxseed ; Sassafras ; Althaea; Quince; 
Tapioca; Arrow Root; Sago ; Barley. 

Family XV.— Emollients : Lard; Cacao Butter; Spermaceti; Lanolin; Glyce¬ 
rin ; Saccharin ; Cosmoline: Poultices. 

Family XVI.— Diluents: Water. 

Family XVII.— Protectives : Soap Plaster; Collodion ; Solution of Gutta- 
Percha. 


DIVISION II—EXTRANEOUS REMEDIES. 

Family I.— Antacids: Liquor Potassae; Sodium and its Salts; Lime, its Salts 
and Preparations. 

Family II.— Anthelmintics: Pinkroot; Azedarach; Wormseed; Koosso; San- 
tonica; Santonin ; Male Fern ; Pumpkin Seed; Turpentine; Pomegranate 
Root and its Alkaloids ; Thymol; Cowhage ; Kamala. 


16 


TABLE OF CONTENTS. 


Family III.— Digestants : Pepsin; Pancreatin; Extract of Malt; Papain. 
Family IV .— Absorbents: Charcoal, Wood and Animal. 

Family Y.— Disinfectants: General Discussion of Use of Heat and Means of 
Disinfecting Apartments, etc.; Lead and Iron ; Copperas; Lime; Corrosive 
Sublimate; Carbolic Acid; Permanganate of Potassium; Chlorine; Chlorinated 
Lime ; Labarraque’s Solution ; Boric Acid ; Borax; Sulphurous Acid. 


APPENDIX. 

Weights and Measures of the United States Pharmacopoeia; Metrical Weights and 
Measures; Relations of Weights and Measures of the United States Pharma¬ 
copoeia—first, to each other, secondly, to Cubic Measure, thirdly, to the Metrical 
Weights and Measures; Table of the Alcoholic Strength of Distilled Liquors, 
of Wines, and of Malt Liquors; Diagrams of Motor Points. 


A TREATISE ON THERAPEUTICS: 

COMPRISING 

MATERIA MEDICA AND TOXICOLOGY. 


INTRODUCTION. 


In the treatment of acute disease it is essential that the doctor 
in charge superintend very carefully the nursing and hygiene of the 
sick-room, since the result of treatment may depend even more upon 
these so-called minor considerations than it does upon the administra¬ 
tion of drugs. In the treatment of chronic disease the best results are 
to be achieved by the regulation of the habits and mode of life of the 
patient, and by the employment of certain remedial measures other 
than drugs. Of late years the importance of modes of relief other 
than medication has so grown in my estimation that I have con¬ 
cluded in this edition to consider them at some length, and have conse¬ 
quently divided the work into two parts. In the first of these are 
discussed those methods of therapeusis which are independent of 
medicinal substances, while the second part is devoted to the consider¬ 
ation of drugs. 


2 


17 



PART I. 


REMEDIES, REMEDIAL MEASURES, 

AND 

REMEDIAL METHODS WHICH ARE NOT DRUGS. 


PRELIMINARY CONSIDERATIONS. 

The scope of the first part of this book might perhaps with advan¬ 
tage have been made wider than has been done, and certain procedures 
discussed which have been omitted. This, however, would have in¬ 
creased beyond proper limit the size of the treatise, and I believe the 
reader will find most therapeutic subjects which are purely medical 
and have any importance sufficiently considered. As the various sub¬ 
jects treated have no intrinsic relations with one another, I have found 
it impossible to make anything like a scientific classification; but for 
the sake of convenience the matter has been divided into four chapters, 
as follows: 

Chapter I.—General Considerations and Various Miscellaneous Re¬ 
medial Measures, including Massage, Metallo-Therapy, and Feeding of 
the Sick. 

Chapter II.—Treatment of General Bodily Conditions, including 
Exhaustion, Obesity, and the Gouty Diathesis. 

Chapter III.—Heat and Cold. 

Chapter IV.—Electricity. 


18 




CHAPTER I. 


GENERAL CONSIDERATIONS—MASSAGE—METALLO-THERAPY— 

FEEDING OF THE SICK. 

GENERAL CONSIDERATIONS. 

In the treatment of chronic disease it is of the utmost importance 
that the physician inquire minutely into the personal habits of the 
patient and insist upon their regulation in accordance with the needs 
of the case. The importance of the alcoholic habit as a cause of local 
and constitutional disease is recognized by many who fail to perceive as 
clearly the effects of the excessive use of other stimulants. Insomnia, 
general nervousness, and various cardiac derangements are frequently 
the result of the tobacco habit, and will not yield to any treatment 
until the abuse is corrected. Headache, general unrest, nervousness, 
and many other symptoms may be the outcome of excessive tea- or 
coffee-drinking, and especially is this the case when these nerve-stimu¬ 
lants are employed to enable the victim to continue excessive labor. 
Among the lower classes, and pre-eminently among sewing-women, 
the nervines just mentioned frequently replace substantial food, and 
the resulting headaches and nerve-failure are to be relieved only by a 
total alteration of the food-habits. The physician should also carefully 
study the clothing of his clientele: especially is this necessary in re¬ 
gard to young children. Some mothers so overload the child as to 
keep the skin in a condition of habitual relaxation, to impede the 
natural, free movements, and to cause general overheating. More 
frequently, however, young children are clothed too little than too 
much. Bare legs and bare arms in cold climates are a fertile source 
of illness. There cannot be two opinions in regard to the superiority 
of wool over cotton as a material for underclothing. The well-known 
effect of wet clothing in causing colds is due to the rapidity with 
which it conducts heat away from the body. Wet cotton is almost 
as good a conductor of heat as water itself, whereas woollen garments 
when wet still resist the passage of heat. During exercise cotton 
underwear becomes damp with perspiration, and in the subsequent 
cooling of the body fails almost entirely as a protective, whereas a 
woollen shirt under similar circumstances maintains the temperature 
of the vital organs. Modern merino underclothing is essentially 
cotton, and is entirely unfit for wear by delicate persons in cold oi 
changeable climates. Persons who suffer from frequent catarrhs or 

19 


20 


MASSAGE. 


are of a rheumatic or gouty diathesis, or whose nutrition is habitu¬ 
ally feeble, should always wear next to the skin either wool or silk. 
When the question of expense is not vital, heavy silk undergarments 
are as serviceable as those made of wool, and, indeed, in rheumatic 
cases, in my experience, are superior to woollen underwear. In very 
many persons, and especially in those who suffer from frequent diar¬ 
rhoeas and indigestions, or derangements of the abdominal viscera, the 
abdominal bandage should be habitually worn, in addition to the ordi¬ 
nary underclothing. It should be sufficiently wide to cover the whole 
abdomen, should be either of silk or of wool, and should be so made as 
to be readily put on and to fit closely to the body. A simple piece of 
flannel of sufficient size, secured in its place by means of ordinary safety- 
pins, makes, perhaps, as serviceable an abdominal bandage as can be 
obtained. Both abdominal bandage and underclothing should be worn 
at night, although, for purposes of cleanliness, it is preferable to change 
them upon going to bed. 

The physician should always inquire into the bathing-habits of the 
patient. Cleanliness and the maintenance of the proper condition of 
the skin require the use of the bath at least twice a week. In some 
very delicate persons the general bath produces marked depression, 
but this can almost always be avoided by the use of very hot water. 
If the hot or warm bath be employed habitually, it should be prefer¬ 
ably taken at night, and, unless under very exceptional circumstances, 
the hot bath should always be immediately followed by cold sponging 
or the cold shower-bath, or by a plunge into cold water. 

MASSAGE. 

The term massage is used as the generic name for external manip¬ 
ulations which are employed for the purpose of affecting the nervous 
and muscular systems and the general circulation. Such procedures 
have been used from time immemorial upon both man and the 
lower animals. The rubbing and grooming which the race-horse 
receives after the contest is a form of massage which is paralleled 
by the rubbings and manipulations employed by the early Greeks 
and Romans after the struggles in the arena. The power of mas¬ 
sage was recognized by Hippocrates and Celsus; and it is affirmed 
that allusions to it can be found in the writings of the Chinese as far 
back as three thousand years before the Christian era. In Japan 
for many years the practice of massage has been by law entirely in 
the hands of the blind, who acquire, by virtue of the increase of the 
power of touch which follows the loss of sight, marvellous dexterity; 
and the natives of the Sandwich Islands formerly practised a form 
of massage, under the name of lom-lomi , to whose assiduous use has 
been attributed the physical superiority of the royal and noble classes 
over the laboring people. Massage is not rubbing of the skin, although 
it has in all probability grown out of the practice of such rubbing. 


MASSAGE. 


21 


The employment of massage for the relief of disease has two dis¬ 
tinct directions. In the one case it is used to affect the general condi¬ 
tion of the body, and is known as General Massage. In the other 
case it is employed for the relief of local affections, and is known as 
Local Massage. Without entering into a detailed discussion of the 
physiological action of massage, it is sufficient to state that it seems to 
me established that in general conditions of lack of muscular tone, 
nervous exhaustion, and failure of the peripheral circulation it is 
of distinct value, while in some local diseases affecting chiefly muscu¬ 
lar tissue its influence is most pronounced. The practice of massage 
requires a certain amount of native aptness associated with consider¬ 
able training. It is not, however, necessary for the operator to be, as 
some writers affirm, either a lady or a gentleman or a highly-educated 
person. It is essential that the masseur have sufficient knowledge of 
anatomy to understand the general drift of the circulation and the 
positions and shapes of the muscles and of the muscle-masses, that he 
be cleanly and agreeable in person, and that he be possessed of a soft 
but firm hand and grasj), and of some natural manual dexterity. 
Even the most detailed descriptions of the methods of massage are 
scarcely of avail for the purpose of practically learning the art. It 
is almost essential that it be acquired in the first place by personal 
instruction, and finally perfected by practice. Any one who essays 
to learn it solely from books must blunder through a long series of 
attempts, and finally work out a method more or less peculiar to him¬ 
self. I do not, therefore, propose to occupy space with a minute 
description of the methods of massage, but only to sketch the general 
features in as much detail as may be necessary for the instruction of 
the physician who is to direct the treatment and judge of the skill of 
the masseur or masseuse. 

Massage is usually practised upon the bared skin, and I think this 
is preferable, although I have known very skilful and successful 
manipulators who preferred that the patient should have thin, tight- 
fitting underclothes. When a male masseur is used for a female 
patient, motives of delicacy require covering. Except when very firm 
masses of local exudation are to be overcome by local massage, or 
when the female patient is very sluggish and fat and requires ex¬ 
ceedingly powerful massage to produce reaction, the female operator 
should always be chosen for the female patient. The question as 
to whether the skin should be anointed before massage is one 
concerning which practice differs. The object of massage is to affect 
not the skin, but the underlying tissue, and when there is special 
sensitiveness or irritability of the skin there can be little doubt as 
to the imperative necessity of some ointment. Yaseline may be em¬ 
ployed. A very excellent material is pure and fresh cocoanut oil. Only 
so much of the grease should be used as is necessary to render the 
skin soft and pliable and to enable the fingers to glide easily over it. 


22 


MASSAGE. 


The movements of general massage vary in detail in the practice of 
different manipulators. They may, however, all be arranged in three 
groups: first, effleurage, or stroking; second, petrissage, or kneading; 
third, tapotement, or percussion. In properly-performed general mas¬ 
sage all these movements are practised at a single seance in the order 
in which they have been named. It is indifferent whether the operator 
commence at the hands or at the feet, but the stroking movement 
should always precede the others, and be directed from the distal por¬ 
tions of the body towards the centre. In making the strokes both 
hands are employed. The limb is grasped with one hand just above 
the other in such a way that pressure is exerted to some extent by 
the whole palm, but especially by the ball of the thumb and the inner 
surface of the last two phalanges of the fingers. The strokes are 
delivered in the form of an ascending spiral, the two hands being 
moved simultaneously in opposite directions, the lower following 
closely upon the upper; or, in accordance with the practice of other 
manipulators, the hands are moved alternately, the second hand taking 
up the motion of the first hand where it has ceased, and while the 
movement is being executed by the second hand the first hand return¬ 
ing to its original position. The strokes must be made firmly and with 
great regularity. 

In kneading, the endeavor of the operator is to pick up the individ¬ 
ual muscle or muscle-groups between the fingers of the two hands, or 
in some cases between the thumb and finger of one hand, and then to 
roll or squeeze the muscle with a double movement. The primary, or 
pinching, motion is made at right angles to the long axis of the muscle, 
while the secondary movement— i. e., the series of pinchings—is carried 
from the insertion of the muscle towards its origin. If the muscle 
be long and small, so that one hand will suffice for the operation, the 
second hand should follow rapidly upon the first in duplicating the 
stroke. 

Percussion is made either with the points of the fingers brought 
into a line with one another, or with the side of the hand and fingers, 
—in either case the fingers being so held as to have looseness and elas¬ 
ticity. The blows should be very rapidly delivered, each individual 
blow being at right angles to the fibres of the muscles, and the 
whole series of blows ascending from the insertion towards the origin 
of the muscle. 

During prolonged muscular inaction, whether from indolence, dis¬ 
ease, feebleness, or other cause, the muscular structure itself suffers some 
degradation, and the peripheral circulation becomes very feeble. Much 
of the albuminous liquid which escapes from the blood-vessels and 
diffuses itself through the tissues, after serving the purposes of nutri¬ 
tion, is taken up by the lymphatic system and returned to the great 
blood-vessels. If there be any vis a tergo driving this liquid from 
the periphery to the centre, it is so feeble that the return of the 


MASSAGE. 


23 


juices depends chiefly upon the squeezing of the various juice-chan¬ 
nels during muscular contractions. During habitual inactivity the 
movement of fluids in the juice-channels outside of the blood-vessels 
is excessively sluggish, and it is one great object of the stroking move¬ 
ments in massage to force these juices onward: it is for this reason 
that these movements are directed from the periphery towards the 
centre. It is not probable that the whole effect of the stroking is 
mechanical. The influence of peripheral nervous irritations upon 
internal organs and upon the general circulation is recognized by 
almost every one, and every invalid knows the power of soothing 
strokes and touches in relieving nervousness and even pain; while the 
phenomena of so-called animal magnetism indicate very strongly 
that in susceptible individuals apparently trivial peripheral irritations 
may produce profound alterations in the functional activity of the 
cerebrum. General stroking movements, if properly administered, are 
to most persons very quieting, and not rarely, when opportunity is 
afforded, general massage is followed by quiet sleep. 

The kneading and percussion movements of massage act chiefly 
upon the local circulation. By an indirect or reflex action both of 
these processes are believed to have a very distinct effect upon the 
capillary circulation in the parts which receive them, an effect which 
is precisely parallel to the redness of the skin which follows a smart, 
stinging blow with the palm of the hand. Kneading performs, how¬ 
ever, still another function. As the result of distinct pathological 
exudations, such as occur in rheumatic muscular affections and even 
as the result of simple inaction or of a general non-specific but bad 
condition of the system, the fibres of muscles within their sheaths or 
the neighboring individual muscles through their sheaths become 
agglutinated, and even the skin itself may get to be abnormally 
tense and attached to the subdermie tissue,—a condition which, when 
it occurs in the lower animals, is known as “ hide-bound.” Kneading 
especially has power to remove this condition by mechanically loosen¬ 
ing the agglutinated fibres and by so stimulating the local circulation 
as to cause absorption of exudations. It is especially in the carrying 
out of kneading and percussion that a knowledge of general anatomy 
of the muscles is required. 

General massage is employed advantageously in various neuras¬ 
thenic conditions, and forms an important part of the system of treat¬ 
ment known as the Rest-Cure (see page 41). When there is marked 
feebleness or nervousness, massage should at first be practised very 
gently, but, except in rare cases, it will soon be found grateful to 
the patient. During the processes of the rest-cui’e, both massage 
and the faradic current will frequently reveal the existence of un¬ 
suspected spots of tendeimess in various parts of the body. It is 
probable that such tenderness marks local congestions, and in prac¬ 
tice I have found the best results follow from the gradual but per- 


24 


MASSAGE. 


sistent application, day after day, of increasingly powerful massage 
and very rapidly interrupted faradic currents to the centres of ten¬ 
derness, which almost invariably disappear sooner or later. Closely 
allied to these sore spots is the tendei’ness of the so-called spinal irri¬ 
tation, or spinal anaemia. When this spinal tenderness is pronounced, 
great care is necessary in the gradual application of massage and the 
faradic current to the affected region. If the operator be sufficiently 
careful at first to work only upon the borders of the tenderness, 
and gradually to approach the centre, excellent results can usually be 
obtained. Under these circumstances massage is useful not only as 
part of the general plan of treating the constitutional condition, but 
also by its local power in dispersing congestions and allaying nervous 
irritations. In some cases the spots of local tenderness are distinctly 
hard, or the hardness and the sensations of knots or solid places in the 
flesh imparted to the hand of the masseur may be even much more pro¬ 
nounced than the tenderness. In such instances the local congestion 
has gone so far as to produce exudation, and there is agglutination of 
tissues. Massage may be of great service in dispersing the exudations, 
and should be assiduously practised over the affected parts. There 
is reason to believe that even glandular enlargements and dilatations 
of lymphatic channels can be affected by external manipulations. 

The first seance in general massage should not last longer than 
twenty minutes to half an hour, but in a little time a full hour will be 
required. When there is lack of digestive power, constipation, or 
any similar symptom,—the outcome of sluggishness of the abdominal 
circulation and nerve-supply,—local massage of the abdominal and 
pelvic region should be freely employed. 

Abdominal massage for the purpose of affecting circulation in the 
intestines should be performed as follows. For one or two moments the 
abdominal muscles themselves should be kneaded, the individual move¬ 
ments being transversely directed across the muscle-fibres; next, in 
order to influence the small intestines, a series of circular sweeping 
strokes should be made around the umbilicus, one hand following the 
other rapidly so as to complete the circles, firm pressure being insti¬ 
tuted with the outer portions of the palms; then kneading movement 
should be performed, beginning at the region of the ileo-csecal valve, 
each movement being transverse to the course of the large intestine, 
the series of the movements following the large intestine upwards to 
the hypochondriac region, then transversely, and finally downwards 
along the whole course of the colon. In some cases, especial^ when 
there is enlargement of the liver with torpor, good is to be achieved 
by kneading movements directly over and upon the diseased organ. 
When along with the enlargement of an abdominal viscus there is a 
condition of softness, great care should be exercised not to injure the' 
organ by too firm pressure. This applies especially to the pulpy con¬ 
dition of the spleen sometimes seen in malarial disease. 


MASSAGE. 


25 


The treatment of sprains by local massage belongs to the province of 
surgery rather than to that of medicine, and 1 have had little experience 
with it. I have in a few cases found it very useful after the first 
stages of irritation and inflammation had passed. I do not think that 
massage ought to be practised within forty-eight hours after a severe 
sprain. In muscular rheumatism or chronic inflammation of the fibrous 
tissues about the joints local massage is of very great value, especially 
when combined with judicious passive movements. The good achieved 
is probably the result of the breaking up of adhesions between and 
within muscles, of the mechanical dispersion of exudations, and of in¬ 
crease of the local circulation, with its consequent absorption of exu¬ 
dation. The important movements are those of kneading and percus¬ 
sion. Whilst the individual movements of kneading: or of striking; are 
chiefly at right angles to the course of the muscle, the whole series of 
pinches or blows should always progress along the muscle, and usually 
from the point of insertion towards the origin. The attempt should 
be to knead not only individual muscles, but also muscle-groups, and 
the movements should be directed especially to the breaking up of 
adhesions. 

In various forms of pai’alysis local massage is of great value as 
a means of maintaining the nutrition of the affected muscles. When 
the lesion which produces the loss of power affects the cerebrum, the 
muscles do not suffer in their nutrition except secondarily from inac¬ 
tivity, and massage is usually not required in the early weeks of the 
affection. After a stroke of hemiplegia it is rarely proper to begin 
massage for two or three weeks; but. whenever the temperature of 
the arm decidedly and permanently falls, or serous exudation into the 
cellular tissue marks a loss of vascular tone, or when evidences of 
returning control over the muscles are manifest, local massage is often 
of service. At first the seance should not last more than five min¬ 
utes, but after a time it may continue for ten or even fifteen minutes. 
In those forms of palsy, such as infantile paralysis, in which the trophic 
centres in the spinal cord are especially implicated, massage is of great 
importance. In acute cases it should be commenced as soon as the 
subsidence of fever and other symptoms of constitutional irritation 
marks the passage of the first stage of activity in the spinal lesion. 
When the infantile paralysis develops gradually, massage may be em¬ 
ployed as soon as the paralysis is recognized. It does not directly 
influence, to any extent, the fundamental spinal lesion, but, by main¬ 
taining a healthy condition of the peripheral apparatus, is of the great¬ 
est service in those cases in which there is a tendency to more or less 
complete repair of the structure of the spinal cord. In various local 
paralyses, as from pressure, from rheumatic affections of the nerves, 
or from other temporary or removable conditions of nervous or mus¬ 
cular tissue, massage may do much good. When the loss of power in 
a muscle is due to direct violence, as occurs with especial frequency 


26 


FEEDING OF THE SICK. 


in the deltoid muscle from falls on the shoulder, massage should be 
assiduously employed as soon as the primary inflammation produced by 
the injury has subsided. In such cases the treatment is of especial 
advantage in dispersing exudations and restoring the muscles and 
the muscle-fibre bundles to their normal relations and their normal 
looseness. 


FEEDING OF THE SICK. 

The present article is not a treatise upon diet or dietetics; the books 
upon this subject are sufficiently numerous, but their scope is often too 
wide for the needs of the medical practitioner. In elaborate discus¬ 
sions upon the contained percentage of nitrogen and general food-quali¬ 
ties of various articles of diet, upon their cost and commercial history, 
upon the amount of food necessary to sustain life, and upon the most 
economical forms of military, prison, and hospital rations, etc., the 
consideration of the feeding of the sick in private practice is often so 
overwhelmed as to be lost entirely. I propose to give here a brief 
practical summary of the methods of feeding in sickness when pecu¬ 
niary considerations are of secondary importance. 

The proper feeding in acute diseases accompanied with high fever 
varies to some extent according to the individual affection, but is 
subject to general principles which are sufficient practical guides for 
most cases. All such acute diseases are for present purposes readily 
divided into those in which the acute febrile stage is very short 
and those in which it is prolonged. When the acute febrile stage is 
very severe and temporary, it is usually associated with a complete 
anorexia, which the practitioner may obey with safety. In the 
first day or two of the onset of an acute pneumonia, violent scarlet 
fever, or similar affections, there is no cause for alarm even if the 
patient take no food. The digestive power at this time may be 
in complete abeyance. After, however, the first day or two of such 
an attack, and whenever the febrile reaction is prolonged, a loss 
of appetite amounting even to a disgust with food is no excuse for 
abstinence. All such states, with their accompanying diseases, tend 
to fatal result through exhaustion, and much can be done by proper 
feeding to prevent complete failure of vital power. The older writers 
upon dietetics taught that a fever patient was not to be fed, and some 
modern authors reiterate the old dictum. Fever is not, however, any 
contra-indication to food. It is, indeed, usually associated with loss of 
digestive power, and if under such circumstances the stomach be over¬ 
loaded with coarse food the symptoms will be aggravated by the result¬ 
ing acute indigestion. The amount of nourishment received by a body 
is measured not by the amount of food put into the stomach, but by 
the amount which is assimilated ; and in febrile complaints the effort of 
the physician must be directed not to the filling of the stomach, but 
to the obtaining of as large an assimilation of food as is possible with- 


FEEDING OF THE SICK. 


27 


out disturbing the alimentary canal. Any symptoms of gastric or in¬ 
testinal disturbance should be the signal for the immediate lessening 
of the food. Such gross manifestations as vomiting, sour or nauseous 
eructations, and gastric distress are perceived at once by the most 
careless; but in typhoid fever I have seen skilful practitioners over¬ 
look the real cause of an excessive tympany or an increased diarrhoea, 
and continue the overfeeding while attempting to relieve these symp¬ 
toms by medicine. Such practice is exceedingly reprehensible. In 
febrile adynamic diseases the feeding should be at short intervals, 
with small amounts of liquid food of a nutx-itious, easily-digested char¬ 
acter, and my own experience leads me more and more to the habitual 
use of foods which have been partially digested artificially. 

The question of night-feeding in severe cases is an important one. 
My belief is that death occurs much more frequently in adynamic 
diseases between one and five o'clock in the morning than at any 
other time,—a circumstance largely attributable to the habitual with¬ 
holding of food and stimulants during the night. Sleep is essential to 
the recuperation of vital force, but an exhausted patient usually goes 
to sleep readily after the partial awakening which is sufficient for the 
administration of a milk punch, or else sleeps in so broken a manner 
that the careful nurse can give the food at short intervals without awa¬ 
kening him. In no typhoid case of severe type should an interval of 
more than three hours be allowed to elapse at night without food and 
stimulants, and the amount given at a single time should be so increased 
that almost as much will be taken during the night as during the day. 

In typhoid eases alcohol in some form should be given with the 
food, in not too large proportion. Alcoholic liquors in moderate 
amount stimulate the stomach and aid digestion and absorption, but 
in large amount interfere with these processes. It may be set down 
as a general rule with few exceptions that all foods given in protracted 
febrile states should be in liquid form. 

Liquid foods may be divided into Liquid Meat Foods, Milk Foods, 
and Artificially Digested Foods. 

Liquid Meat Foods. —It must be remembered that all articles of 
the present class are stimulants rather than nutrients. Most of them 
do not contain more than one per cent, of albuminous substances. 
Under this heading I include all liquid preparations of meat made 
without artificial digestion. 

At one time these liquid preparations of meat were supposed to 
represent the whole nutritive value of the meat, but recently all nutri¬ 
tive power has been denied to them. They contain kreatin, kreatinin, 
sarkosin, sarkin, xanthin, kreanin, inosite, fat, and inorganic salts, with 
a very small amount of albuminous principles. It is not probable 
that any of these substances, except the albumen and the fat, are 
capable of being assimilated and used as food. The experiments of 
Kemmerieh also indicate very strongly that they are not nutrients, for 


28 


FEEDING OF THE SICK. 


he found that animals fed exclusively upon these preparations died 
even more quickly than those left to starve. There can be no doubt 
that the death under these circumstances was largely due to the de¬ 
pressing effect of the inorganic salts contained in the extracts. Clinical 
experience, in a measure, conforms with this scientific reasoning. At a 
time when beef essence and beef tea were very largely relied upon as 
nutrients in Philadelphia, it was found that they acted better when 
milk was also given. In my earlier trips into the wilderness, involving 
much physical labor, I took with me the best artificial meat extracts 
to serve as condensed food, but, after a few trials, found that they were 
unable to sustain prolonged effort,—as the guides put it, “ they do not 
stick to a man’s ribs,”—and, although at that time my theoiy was that 
they were concentrated nourishment, practical experience soon led to 
their abandonment. Although of little use as food, these substances 
are valuable stimulants, and may by reviving temporarily an exhausted 
patient prepare the way for the digestion of food. In a series of ex¬ 
periments made upon the frog’s heart by Dr. Thomas J. Mays ( Therap . 
Gaz., vol. ii. p. 152), it was found that the artificial beef extracts and 
concentrated beef preparations had a very decided influence in main¬ 
taining the activity of the systoles. Notwithstanding Dr. Mays’s 
arguments to the contrary, however, I believe that the effect of beef 
extracts upon the frog’s heart is entirely similar to that of the phos¬ 
phate of calcium (see Calcii Phosphas). In typhoid and other simi¬ 
lar low fevers, it is an excellent plan to give beef essence or beef tea 
alternate hours with milk punch. During convalescence a hot bowl of 
beef tea or beef essence after exertion such as carriage-riding, going 
out, etc., may act very well as a stimulant. By the addition of 
various substances these liquid preparations of meat can be made nutri¬ 
tive : thus, an egg rapidly stirred into a bowl of beef essence forms a 
very useful stimulating food. There are in the market various extracts 
of beef, claiming to represent, in a solid form, beef essence. The better 
forms of these articles undoubtedly do represent in great part beef 
essence, but they are distinctly inferior to the freshly-made prepara¬ 
tion in taste, and in containing no albumen: so that it is always better 
to employ the fresh beef essence if it can be procured. 

Liquid meat foods are divisible into those that are raw and those 
that are cooked. Of the raw foods of the class, the best is meat juice. 
This is made, according to the directions of Pettenkofer and Yoit, by 
selecting lean meat from the round of beef, cutting it into small pieces, 
and expressing the juice in a press of sufficient power,—such as now 
can be purchased at any of the larger drug-stores. This juice contains, 
in addition to the salts and extractives, the albumen that remains fluid 
after the rigor mortis,—chiefly serum-albumen and coloring-matters. 
The proportion of albumen is about six per cent.: by heating the albu¬ 
men is precipitated, but it is not affected by salt or by mere warming. 
Liebig's beef tea is made by adding seven ounces of water and three or 


FEEDING OF THE SICK. 


29 


four drops of hydrochloric acid to one and a half pounds of lean beef, 
allowing to stand one hour, passing through a hair sieve, and washing 
out the meat with three ounces of water. This infusion contains, on 
the average, not more than one per cent, of albumen. The hydro¬ 
chloric acid added to the water is not sufficient to dissolve the myosin 
of the muscle: so that this preparation can be looked upon as nothing 
more than a dilution of meat juice, and is very inferior. To have any 
effect it must be given in enormous quantities. 

Meat juice is a valuable preparation when a powerful stimulation is 
desired and the digestive forces are exceedingly weak, as in the feeble¬ 
ness or collapse that follows cholera infantum and other infantile diar¬ 
rhoeas. Its taste is that of raw meat, and is so disagreeable to many 
persons as to prevent its use. 

The cooked concentrated liquid forms of meat extracts are beef tea 
and beef essence. Neither of these can be considered to have distinct 
nutritive value. It is very rare for them to contain more than one per 
cent, of albuminous substances; but they are powerful stimulants, and 
for such purposes are as useful as the expressed meat juice. 

In making beef tea the round of a good piece of beef should al¬ 
ways be selected, and cut into small cubes not larger than half an 
inch in diameter. It should then be put to soak for two hours on the 
back of the range, in an earthen-ware pipkin, with one pint of cold 
water, and allowed to simmer for about fifteen minutes and finally to 
boil for three minutes. After adding half a teaspoonful of salt and a 
little pepper the tea is ready for use. 

In making beef essence the meat should be prepared as for beef tea. 
It should be put into an earthen-ware bottle and loosely corked. This 
should be set in a pot of 'cold water and brought very gradually to 
the boiling-point. It then should be allowed to boil for from twenty 
minutes to half an hour. 

Soups are liquid preparations which resemble beef tea and beef es¬ 
sence in containing the extractives of meat, but which differ from these 
preparations in having in them various nutritive substances. Soup is 
therefore both a stimulant and a nutrient, the amount of nutrient ma¬ 
terial varying greatly according to the preparation of the soup. The 
lighter forms of soups are commonly spoken of as broths. They may 
be used when the stomach rejects less readily digested forms of food. 

To make chicken broth, take thfee pounds of chicken well cleaned, 
cover with cold water, boil from three to five hours (until the meat 
falls to pieces), strain, cool, and skim off the fat. To a pint of this 
add salt and pepper and two tablespoonfuls of soft rice which has been 
previously thoroughly boiled in salt water; bring the broth to a boil. 
In preparing the rice, half a cupful should be boiled for thirty min¬ 
utes with a teaspoonful of salt in a pint of water. To make mutton 
broth , take one pound of lean, juicy mutton, chopped fine, and proceed 
as with chicken broth. 


30 


FEEDING OF THE SICK. 


In the preparation of soups the first thing is the making of the 
so-called stock, or basis for the soup. There are two distinct stocks: 
one which may be known as the brown stock, the other as clear stock 
or consomme. For the preparation of brown stock take four pounds of 
shin of beef, four quarts of cold water, ten whole cloves, four pepper¬ 
corns, a bouquet of herbs (sweet marjoram, summer savory, thyme, 
and sage), one tablespoonful of salt, three small onions, one turnip, 
one carrot, two stalks of celery, two sprigs of parsley. Cut the meat 
from the bones, after which place the bones and one-half of the meat 
in a soup-kettle and allow to stand for half an hour in the cold water. 
Heat gradually, and allow to simmer for six or seven hours. Brown the 
remainder of the meat in two tablespoonfuls of beef-drippings, and add 
with the other meat and with the vegetables chopped fine, when the 
kettle is put on the fire to simmer. After it has simmered the re¬ 
quired time, the stock is strained and set aside to cool, the fat being 
removed from the top. The stock is then ready for use. 

In making the soups the stocks must never be allowed to boil, or 
at most must be brought only for a moment to the boiling-point. For 
St. Julienne soup put one pint of the brown stock on the fire to heat, 
after which a pint of finely-chopped vegetables (turnip, carrot, etc.), 
with half a teaspoonful of salt, should be put on with a little water to 
parboil. This being done, add the vegetables to the stock, and season 
with half a saltspoonful of pepper. Vermicelli soup is made by adding 
half a cup of vermicelli to a pint of the brown stock. Cook the ver¬ 
micelli for ten minutes in salted boiling water, season with a half-tea- 
spoonful of salt and a half-saltspoonful of pepper, and add to the warm 
stock. 

Consomme or clear stock is to be made in exactly the same way as 
the brown stock, except that three pounds of the knuckle of veal are to 
be added to the meat, and all the meat is to be put in at once without 
browning. After the stock has been formed, in order to clear it add 
the white and the shell of one egg. and the juice and rind of one lemon, 
beating them all up together; then put on the fire, bring to the boiling- 
point, strain through a sieve, and again through a napkin, Avithout 
pressure or squeezing, and serve. 

A very elegant stimulating and nutritious soup can be made out of 
consomme by boiling ordinary pearl sago in salt water for from two to 
three hours, until the grains become SAvollen almost to bursting, and 
then stirring the sago into the consomme while still boiling. 

Milk Foods.— Of all liquid foods milk is the best and the most 
generally applicable to the treatment of disease. Cow’s milk contains, 
in round numbers, 87.5 parts of water, 3 parts of caseine, 0.75 part of 
albumen, 3.6 parts of fat, 5 parts of sugar, and 0.07 part of inorganic 
salts. One pint of milk contains, in round numbers, 0.6 ounce of solid 
albuminous substance, 0.6 ounce of fat, and 0.8 ounce of sugar. When 
two quarts of milk are taken in the course of twenty-four hours, about 


FEEDING OF THE SICK. 


31 


two and a half ounces of fat are ingested,—an amount too great for 
an inefficient alimentary canal to digest, so that it is often necessary to 
skim the milk. As milk contains practically no indigestible residue, it 
leaves behind it in the alimentary canal no faecal matter, and its use 
therefore frequently produces constipation. In cases of diarrhoea this 
tendency to a binding action can be increased by boiling the milk, a 
process which coagulates the albumen of the milk and slightly lessens, 
if the scum be removed, its nutritive value. When milk is used very 
freely and the digestion is feeble, there is always danger of the forma¬ 
tion in the stomach of a coagulum so dense that the gastric juice will 
not be able freely to penetrate it. This difficulty can usually be over¬ 
come by a little care. The addition of half an ounce to an ounce of 
lime-water to every five or six ounces of milk has a distinct tendency 
to prevent too rapid and than coagulation. Sipping milk instead of 
drinking it—in other words, putting the milk in the stomach in small 
quantities at a time—has a still greater power in repressing the forma¬ 
tion of hard coagulum. When the digestive powers are feeble, milk 
should be taken slowly in small quantities at a time. In some cases it 
is very important that it be drunk hot, but without previous boiling. 

There are various useful nutrient and stimulant foods prepared 
with alcohol in milk, as follows : 

Wine Whey. —Bring half a pint of milk to the boiling-point; 
add half a pint of sherry wine, and allow to stand in a warm place 
for five minutes; strain, and sweeten to taste. The whey which is 
left consists almost exclusively of wine and water, with milk sugar 
and milk salts. It contains very little nutriment, but is sometimes 
tolerated by the stomach which refuses other food. 

Milk Punch. —Take half a pint of milk; pour into it from a des¬ 
sertspoonful to a tablespoonful of brandy, rum, or whiskey, according 
to the needs of the patient; sweeten and spice with nutmeg to taste. 
This preparation represents all the nutritive value of milk and the 
stimulating effects of the liquor. If the stomach be at all delicate, 
a tablespoonful of lime-water should always be added to it before 
putting in the brandy. 

Eggnog.—E ggnog is a heavy, rich, highly nutritive liquid, which 
must be employed in limited quantities, and very carefully when there 
is any delicacy of stomach. The yelk of one egg may be added to half 
a pint of milk, afterwards half an ounce to an ounce of brandy, and 
the Avhite then beaten in. 

Sometimes when the stomach rejects almost all forms of food, the 
addition of carbonic acid water to the milk meets with success. Equal 
quantities should be employed, and the caseine of milk should be coagu¬ 
lated in fine flakes. A light, powerfully stimulant beverage, somewhat 
similar to the one just mentioned, but to some palates more elegant, 
is made by the addition of champagne to milk. 

There are certain forms of fermented milk which are valuable as 


32 


FEEDING OF THE SICK. 


being easily digested by the stomach and very acceptable to the palate. 
They also render possible some variety of food to persons largely 
restricted to milk diet. 

Koumiss, or Kumys, is a fermented liquid prepared by the Tartars 
from mares’ milk. It may for ordinary purposes be sufficiently imi¬ 
tated by the following recipe. Take an ordinary beer-bottle with a 
patent shifting cork, put in it one tablespoonful of white sugar, one 
pint of milk, one-sixth of a cake of Fleischman’s yeast or one drachm 
of strong liquid yeast, shake well, allow to stand from eight to ten 
hours in a temperature of from eighty-five to ninety-five degrees, 
shake well, and put upon the ice to cool. This ought to be used within 
twenty-four hours after being made. The longer the fermentation 
is allowed to continue, the more sour is the koumiss; and its condition 
should be regulated to suit the individual palate and stomach of the 
patient. If it be desired, it may be flavored by the addition of a small 
piece of vanilla bean to the milk before fermentation. This prepara¬ 
tion is suited to the treatment of convalescence and chronic diseases 
rather than of acute febrile illness. 

Milk may be used as the basis of a number of farinaceous or starchy 
liquids. It must be remembered that these starchy compounds are 
more or less difficult of digestion, and during the progress of an acute, 
severe febrile illness they must be employed with the greatest caution. 
In convalescence and in chronic invalidism, however, they are often 
very serviceable. In making these preparations it is essential that 
they be closely watched and stirred, to prevent burning, unless they be 
cooked over hot water. 

Oatmeal Porridge may be made by stirring two ounces (half 
a cupful) of crushed oatmeal into a pint of milk, previously warmed, 
and afterwards cooking twenty to thirty minutes, adding salt to the 
taste. 

Baked Flour Porridge. —A very excellent porridge, of easy diges¬ 
tion, and especially valuable when there is a tendency to looseness of the 
bowels, can be made by the following recipe. Take one pint of flour 
and pack it tightly in a small muslin bag, throw it into boiling water 
and boil for five or six hours, cut off the outer sodden portion, grate 
the hard core fine, and stir into boiling milk to the desired thickness. 

Arrow-Koot Porridge.— This may be prepared in the following 
manner. Stir two teaspoonfuls of arrow-root in half a teacupful of cold 
milk until a perfectly sviooth mixture is made; have on the fire a pint 
of milk, and, while this is boiling, add the arrow-root little by little, 
stirring constantly until cooked,— i.e., from one to two minutes after 
the last is poured in ; add sugar, nutmeg, and wine, according to taste 
or the exigencies of the case. When milk is not to be had, or a very 
low diet is required, water may be substituted. 

The secret of properly-prepared arrow-root is in having the first 
mixturo with milk absolutely smooth and free from lumps. 


FEEDING OF THE SICK. 


33 


Chocolate Porridge.— A gruel which will be found very palatable to 
many persons, and may be substituted for simple arrow-root, can be made 
by the following recipe. Mix together one-quarter pound of best choco¬ 
late grated, one-half pound of rice flour, two ounces of arrow-root, and 
one-quarter pound of loaf-sugar grated. Add a tablespoonful of this 
mixture to a pint of hot milk, and let it boil five minutes. Then re¬ 
move the preparation from the stove and serve it hot. It should have 
the consistency of gruel. 

Tomato Porridge. —A very excellent porridge or piwee, highly nu¬ 
tritious and useful during convalescence, can be made by the following 
recipe. Take one quart of canned tomatoes, bring to a boil, strain 
while hot through a hair sieve; bring a quart of milk to a boil, add 
sufficient flour to make a thick paste, stir in, and continue to boil until 
the flour is cooked (about twenty minutes). Stir the strained tomatoes 
gradually, a little at a time, into the boiling milk. Cook five or ten 
minutes; season to taste. 

Sago Porridge is of the consistency of a jelly rather than of a por¬ 
ridge. In preparing it, wash the sago well in cold water, put a small 
teacupful of it to soak in half a pint of water over-night, and in the 
morning put this mixture into one pint of hot water; squeeze into it 
the juice out of a thinly-pared lemon, and allow to simmer slowly for 
twenty minutes; then sweeten, add wine according to taste or the 
exigencies of the case, and pour into moulds to cool. 

Tapioca Porridge is very elegant, but, like sago porridge, requires 
considerable time for preparation. It may be made in the following 
manner. Soak two tablespoonfuls of very clean tapioca in two teacup¬ 
fuls of cold water over-night; in the morning add a little salt and one 
pint of milk, or water if milk is not allowed; simmer it until quite 
soft; stir well while cooling; when done, pour into a bowl, and add 
sugar, wine, and nutmeg, according to taste or the exigencies of the 
case. 

Artificially digested Foods. —In low fevers the powers of the 
alimentary canal are certainly much impaired, and foods which have 
undergone more or less complete artificial digestion outside of the body 
are very useful. 

In all cases in which the typhoid symptoms are severe, milk 
should constitute the chief reliance, and should be partially digested 
before administration. When the disease is prolonged, and especially 
when the mental condition is clear, the patient frequently tires of 
milk. Under these circumstances various liquid foods prepared by 
the partial digestion of solids are of great importance. Artificially 
digested foods are also of value during convalescence, and their em¬ 
ployment constitutes a very important part of the treatment of gastric 
and intestinal catarrhs. Most peptones have a distinctly bitter taste, 
which may be very objectionable in individual cases. This taste can 
be partially overcome by the addition of flavoring substances or ex- 

3 


34 


FEEDING OF THE SICK. 


tracts, and often may be altogether avoided by arresting the process 
of artificial digestion before completion. 

At first thought pepsin would appear to be the most available 
ferment for the preparation of peptones; but practical experience 
has led to reliance upon pancreatin. Pancreatin, pancreatic extracts, 
and pancreatic liquors are now found abundantly in commerce. The 
superiority of the secretion of the pancreatic gland as a practical fer¬ 
ment is connected with the fact that it contains two distinct classes of 
digestive principles, namely, pancreatic diastase, which dissolves starch, 
and trypsin, which acts upon albuminous principles. It is of great 
importance to be able to determine readily the value of any prepara¬ 
tion of pancreatin. The test devised by Dr. Wm. Roberts (Digestive 
Ferments , London, 1881) appears to be very practical. If pancreatin 
be added to fresh milk without an alkali, in the course of a few minutes 
the liquid acquires the property of curdling abundantly upon boiling; 
and Dr. Roberts estimates the value of a pancreatin by the number of 
cubic centimetres of milk which are transformed by one cubic centi¬ 
metre of the sample at a temperature of 40° C. to the curdling-point 
in five minutes. The liquor pancreatieus used by Dr. Roberts had a 
power oscillating between fifty and seventy. A test which may be 
substituted for that of Dr. Roberts, and which is especially applicable 
to the ordinary pancreatic extracts or so-called pancreatin, is based 
upon the peptonizing power of the powder. Five grains of it added 
to twenty grains of the bicarbonate of sodium should so alter the 
caseine contained in one pint of milk in an hour at a temperature 
of 115° F. that no coagulation will occur upon the addition of nitric 
acid. 

Peptonized milk is made by diluting a pint of milk with a quarter of 
a pint of water, heating to about 140° F., adding two teaspoonfuls of 
liquor pancreatieus (Roberts’s) with twenty grains of bicarbonate of so¬ 
dium, digesting in a warm place for an hour to an hour and a half, and 
raising momentarily to the boiling-point; at the temperature of the sick¬ 
room, 65° F., the digestion will usually require about three hours. Or 
milk may be peptonized by dissolving five grains of pancreatin with 
twenty grains of bicarbonate of sodium in an ounce of warm water, 
adding to a pint of milk, and keeping at a temperature of 110° for one 
hour. Very many persons object to the bitter taste of the thoroughly 
digested milk, so that in practice the best results are often obtained by 
allowing the peptonizing process to be only partially completed, and 
giving the milk after it has been acted upon by the ferment not longer 
than twenty to thirty minutes. 

Peptonized milk gruel is made by first preparing a thick gruel with 
arrow-root, oatmeal, sago, or other similar farinaceous articles, adding, 
while still hot, an equal quantity of milk, and subsequently, when 
cooled to 100°, for each pint twenty grains of the bicarbonate of 
sodium and two teaspoonfuls of the liquor pancreatieus or five grains 


FEEDING OF THE SICK. 


35 


of pancreatic extract, digesting in a warm place for two hours, boiling 
the mixture momentarily, and straining. 

Peptonized beef tea is prepared by simmering half a pound of minced 
beef for two hours in a pint of water containing twenty grains of 
bicarbonate of sodium, allowing to cool to about 100° F., digesting at 
this temperature with a tablespoonful of liquor pancreaticus or ten 
grains of pancreatic extract for three hours, decanting, and momentarily 
boiling. This beef tea is said to be about equivalent to milk in nutritive 
value, containing 4.5 per cent, of organic solids, three-fourths of which 
is peptone. 

Peptonized oysters , a very palatable and extremely nutritious dish, 
is made by mincing six large or twelve small oysters, and adding to 
them, in their own liquor, five grains of pancreatic extract with twenty 
grains of bicarbonate of sodium. The mixture is then to be brought 
to 100° F., and maintained, with occasional stirring, at that tempera¬ 
ture for thirty minutes, when one pint of milk is to be added and the 
temperature steadily kept up for ten to twenty minutes. Finally the 
mass is to be brought to the boiling-point, strained, and served. Gela¬ 
tin may be added, and the mixture served cold as a jelly. Cooked 
tomato, onion, celery, or other flavoring suited to the individual taste 
of the patient may be added at the beginning of the artificial digestion. 

Pancreatized Milk Toast. —Ordinary milk toast, in which there 
is an abundance of milk, when digested for thirty to fifty minutes 
with pancreatin and bicarbonate of sodium becomes an almost homo¬ 
geneous pulpy mass, which, when the crusts have been removed, is 
usually readily retained by the irritable stomach. In extreme cases, 
however, it may advantageously be strained and the fluid portion alone 
used, in which the partially peptonized solution of caseine of the milk 
is reinforced by the actually digested gluten and starch of the bread, 
together with a very little dextrin. Plain, light sponge-cake may be 
similarly digested, and occasionally forms a desirable change. 

Kectal Alimentation. —In severe gastritis and in gastric ulcer it is 
sometimes necessary to enforce a temporary or even a somewhat pro¬ 
longed abstinence from food. In diphtheritic paralysis of the throat, 
as well as in strictures of the oesophagus, it may be almost impossible to 
get food into the stomach, and in various cases the food is vomited 
whenever it is ingested. Under any of these circumstances feeding by 
the rectum becomes a matter of the utmost importance. There is no 
reason for believing that the rectal or even the colonic secretions have 
digestive power. Absorption goes on slowly from the rectum, but, ac¬ 
cording to Landois, very rapidly from the colon itself. For these rea¬ 
sons injections which are used for the purpose of nourishing the patient 
should always be composed of bland, thoroughly digested, concentrated 
food. Dr. W. 0. Leube ( [Deutsch. Archiv fur Klin. Med., 1872) uses a 
food preparation which he has proved by experiments made upon dogs 
to be capable of yielding to the blood nutritive material, and by which 


36 


FEEDING OF THE SICK. 


lie has maintained life for four weeks in a patient poisoned by iodine, 
whose stomach rejected all food. The method is as follows. The pan¬ 
creas of swine or cattle is carefully cleaned of fat, and 50 to 100 grammes 
thereof cut into very small pieces. In like manner 150 to 300 grammes 
of beef are prepared. Both substances are then put into a dish with 
about 50 to 150 cc. of lukewarm water, and stirred into a thick paste, 
and drawn in a clyster-pipe with wide opening. In many cases from 25 
to 50 grammes of fat may be added to the mixture, also at times some 
starch. An hour before using this clyster, one of pure water should be 
administered, to clean out the intestines. In very warm weather there 
is some trouble in obtaining and keeping sweet the pancreas. This 
difficulty may be avoided by making a glycerin extract, which is said 
to be quite equal in digestive power to the fresh pancreas, and will 
remain good for several weeks. The following is the manner of its 
preparation: the pancreas of a bullock (which is sufficient for three 
enemata) is finely chopped, and rubbed with 250 grammes of glycerin; 
and to each third of this, when about to be used, are added from 120 to 
150 grammes of finely-divided meat. It is important that this mass 
should be injected into the intestine as soon as it is made; for if it is 
allowed to stand, the meat swells, and the operation is thereby rendered 
difficult. 

It is evident that the central idea of Dr. Leube’s method is simply 
to offer to the intestine for absorption a well-formed peptone. Dr. L. S. 
Joynes (Richmond and Louisville Med. Journ ., 1869) has found that tho 
stomach of the pig placed in water acidulated with hydrochloric acid 
will rapidly dissolve not only itself, but also small pieces of beef. Such a 
preparation might be substituted for that of Leube, but, as its reaction 
would be acid, it would probably not agree so well with the intestine. 
The solutions of Leube can very well be substituted by preparations made 
with commercial pancreatic extracts. As milk and eggs contain all the 
food necessary for the sustenance of life, and are more rapidly and 
readily digested than is meat, all that is necessary is to digest them 
thoroughly before injection. Half a pint to a pint of milk with two 
or three eggs may be employed at each injection. When stimulants are 
required, half an ounce to an ounce of brandy may be added to each 
injection: larger quantities of alcohol than these would be apt to irritate 
the mucous membrane. The alcohol should always be added after di¬ 
gestion has taken place, and just before administration. A practical 
difficulty in sustaining life by rectal injections is the frequent refusal 
of the intestine to retain them. In order to obtain the best possible 
results, certain precautions are necessary. The colon and rectum 
should always be free from faeces before the administration of the injec¬ 
tion. The injection should be given at the temperature of the body, 
thrown in very slowly, and as high up into the intestine as possible. 
The effort should be to have the fluid injected into the colon rather than 
into the rectum. Unless a narcotic is contra-indicated, from twenty to 


ME TALLO- THERAPY. 


37 


forty drops of laudanum should be added to each injection. Yery rarely 
is it wise to repeat the injections oftener than twice in the twenty-four 
hours; and once in eight hours is the extreme limit. 

METALLO -THERAPY. 

In 1849, Dr. Burk discovered that in hysterical anaesthesia it was 
possible, by the application of metals to the surface of the body, to 
recall sensibility, and in 1851 he presented an inaugural thesis upon 
the subject to the Faculty of Paris. It was not, however, until 1876 
that he succeeded in attracting the general professional attention of 
France to the matter. In that year, in answer to his importunities, 
the Societe de Biologie of Paris appointed a commission to examine 
into the accuracy of his alleged facts. The report of this commission 
(Paris, 1879) confirmed the statements of Dr. Burk, and also ex¬ 
tended our knowledge of the subject. It was found that different indi¬ 
viduals have different relations with metallic substances, some cases 
being affected by zinc, others by iron, others by gold, copper, etc. In 
exceptional instances the hysterical person has relations with two or 
even more metals. When a small disk of the appropriate metal is bound 
over the anaesthetic surface of an hysterical subject, after from ten to 
twenty minutes a sensation of warmth is developed beneath the disk, 
and a distinct reddish color appears. At this time the prick of a needle 
is distinctly felt, even painfully so, not only at the spot over which the 
plate has been applied, but also in a more or less extended zone around 
it. In some cases the sensibility returns only in the immediate vicinity 
of the application; in others the whole arm or, more rarely, the whole 
side of the body becomes sensitive. With the return of sensitiveness 
there is a disappearance of the ischaemia, and if motor palsy has ex¬ 
isted there is also an increase of the motor power as measured by the 
dynamometer. In most cases of hysterical anaesthesia there is a distinct 
coldness of the surface, or, indeed, of the whole arm, and with the dis¬ 
appearance of the palsy of sensation and of motion there is an increase 
in the temperature. Thus, in a case of right-sided hysterical anaesthesia 
and amyosthenia the thermometer held in the right hand stood at 36° 
C., in the left at 34.5° C. (Dr. Dumontpallier, La Metalloscopie, Paris, 
1880), but after the application of the metal the temperature of the 
left hand was higher than that of the right. In many instances not 
only is the sensibility of the skin restored, but at the same time the 
special senses gradually become nearly normal; although in other cases it 
is necessary, in order to affect the special senses, that the metallic plates 
should be in the neighborhood of the orbit or in the temporal region. 
When achromatopsia is relieved, blue is usually the first color to return, 
or, more rarely, red. Some minutes after this, yellow is perceived, then 
green, and at last violet (Dr. Aigre, La Metalloscopie , Paris, 1879, p. 23). 
As seems to have been first discovered by M. Gelle, at the time of the 
disappearance of the anaesthesia under the influence of the metal the 


38 


METALLO-THERAPY. 


loss of sensibility appears in a corresponding position upon the unpara¬ 
lyzed side, and is accompanied by a fall of the local temperature. In 
a few cases severe pains have developed during the application of the 
metals. According to the experience of the French commission, which 
seems to be identical with that of subsequent observers, the effect of 
the application is usually in hysteria at first temporary, and lasts from 
a few minutes to some hours. 

Dr. Burk, in his communication to the Societe de Biologie, stated that 
if the metal which had been found temporarily to affect sensation in a 
person suffering from hysterical anaesthesia were given to such patient 
in continuous doses, all symptoms of hysteria would, after a time, per¬ 
manently disappear. The commission confirmed, in a measure, this 
statement: in sundry cases they found under such administration that 
menstruation became regular, digestion improved, and the muscular 
force and sensibility returned. They further, however, made the extraor¬ 
dinary discovery that if a piece of the metal were bound down on the 
skin of the person who had recovered, a return both of anaesthesia and 
of motor palsy took place in from twenty to forty minutes. 

It having been suggested that the metal upon the skin acts by in 
duction of the feeble galvanic currents, the French commission found 
that the application of most metals to the surface of the human body 
gives rise to an electric current sufficiently powerful to be measured, 
that these currents vary in power with different metals, and that elec 
trical currents of power equal to that of those produced by the appro¬ 
priate metals applied to the anaesthetic surface brought about a return 
of sensibility. The observations of M. Luys showed that the applica 
tion of the appropriate metals was also able to reduce hysterical hyper 
aesthesia to the normal. 

That the phenomena of the so-called metallo-therapy, as I have 
summarized them, may frequently be obtained, in more or less com¬ 
pleteness, is shown by the confirmation of the report of the French 
commission not only by a number of French observers, but also in 
England by Dr. A. Hughes Bennett ( Brain , vol. i. part 3; Brit. Med. 
Journ., Nov. 25, 1878), in Italy by Buccola and Sepilli ( Lond. Med. 
Record , vol. ix.), and in Germany by Dr. F. Gratz (Ibid.) and various 
other observers. It is, however, certain that, at least in this country, 
they are exceptional. In an elaborate series of observations made in 
the wards of the Philadelphia Hospital by my colleague Dr. C. K. Mills, 
the transfer of sensibility was obtained in only a very few cases; while 
Dr. S. Weir Mitchell affirms, as the result of his great experience, that 
neither he nor any of his assistants have ever been able to bring about 
anaesthesia of the sound side, although they have very frequently ob¬ 
tained temporary returns of sensibility by the application of various 
substances, especially by mustard plasters, and even more pronouncedly 
by freezing the skin with rhigolene. It was at first believed that the 
production of sensibility by aesthesiogenetic agents is proof of the 


METALLO-THERAPY. 


39 


hysterical nature of an anaesthesia; but in the course of his early 
observations upon the subject, M. Charcot found that even in organic 
hemiansesthesia the application of the plates of metal was followed in 
twenty or thirty minutes by a return of the normal sensibility and of 
the special senses. These observations have been confirmed by several 
French observers. 

It is also asserted that if powerful magnets be used instead of metal 
plates, in cases of hysterical or organic hemianesthesia with contrac¬ 
tures and motor palsy, there will be relief not only of the paralysis of 
sensibility, but also of the disturbances of motility. Thus, M. Laboul- 
bene reports a case (Gazette des Hopitctux) of a man, sixty-seven years 
of age, suffering from organic left hemiplegia and complete hemianes¬ 
thesia, in whom the application of a strong magnet was followed by 
the reappearance, first in the arm and afterwards in the leg, of the 
normal sensibility, and by marked increase of the motor power in the 
hand as tested by the dynamometer. It is, however, to be noted that, 
so far as my examinations of the records go, there has not as yet been 
reported a case of organic hemianesthesia in which any transfer of 
anaesthesia has been noted. 

The explanation of the facts of metallo-therapy is a matter of diffi¬ 
culty, and no theory has as yet been offered which is satisfactory. 
That the phenomena are not the result of the action of a feeble elec¬ 
tric current upon the peripheral nerves seems to be shown by their 
having been produced by metals, such as platinum, which are practi¬ 
cally non-oxidizable, and by absolutely inert substances, such as disks 
of wood, and even, as in the case reported by Bennett (Joe. cit.), by the 
application of a handkerchief. The theory adopted by most English 
writers, that they are the result of expectant attention,— i.e., that they 
are the result of the patient’s believing that the phenomena are about 
to happen,—is asserted to be disproved by the fact that in many cases 
the patient did not know what was to happen. The so-called molecu¬ 
lar theory, which teaches that there is some mysterious molecular in¬ 
fluence produced by the applied plate on the peripheral nerve filaments, 
amounts to nothing more than words. 


CHAPTER II. 


THE TREATMENT OF SYSTEMIC STATES. 

EXHAUSTION AND NEURASTHENIC CONDITIONS. 

Depression is a condition of temporarily lowered vital activity 
produced by the presence of some poison in the system. Exhaustion 
is a condition of absolute lack of power in which the functional ac¬ 
tivity is repressed not by a depressing substance, but by the inability 
of the affected part. In practice it is essential to distinguish between 
these two states. The one requires treatment by stimulants, while the 
other is often, although temporarily relieved, permanently aggravated 
by the use of stimulants. Exhaustion, especially of the nervous sys¬ 
tem, is frequently spoken of as a disease, under the name of neuras¬ 
thenia. It is not a disease, however, but a condition, which may be the 
result of overstrain or overwork or of some chronic disease. It is 
essential that in every case of alleged neurasthenia very careful ex¬ 
amination should be made to detect the presence of organic kidney-dis¬ 
ease, chronic diarrhoea, or other possible cause of the exhaustion. The 
amount of work necessary to produce neurasthenic exhaustion is de¬ 
pendent upon the original amount of power in the organism. In 
persons born of neurotic feeble parentage or of parents exhausted by 
overstrain, the working power may be very slight. Exhaustion may 
be local or it may be general. This applies to the nervous system as 
well as to the other apparatus of the body. A local nervous exhaustion 
tends towards developing into a general condition. Thus, a writer’s 
palsy may be the first symptom of a general break-down. Sperma¬ 
torrhoea, at first due purely to local exhaustion of the implicated 
nerve-centres, if unchecked very generally develops into general neu¬ 
rasthenia. The same is true of cerebral exhaustion following excessive 
mental work. The exhaustion is to be relieved only by recuperation, 
and recuperation is to be obtained only by rest and the assimilation of 
food. The nature of the rest depends upon the character of the ex¬ 
haustion. In cases of pure cerebral exhaustion with the bodily powers 
untouched and the physical powers not much implicated, freedom from 
care and from all mental work, conjoined with life in the open air, is 
the essential of cure. It must be remembered that sight-seeing is as 
exhausting to the brain as is the hardest study, and that in extreme 
cases even the seeing of friends may overtax the brain so that isolation 
may be essential. Such isolation may be obtained, if the bodily powers 
40 


EXHAUSTION AND NEURASTHENIC CONDITIONS. 41 

remain good, by travel in the wilderness, or on the ocean, or in other 
positions where intercourse with the world is impossible. In cases of 
extreme neurasthenia or nervous exhaustion the so-called rest-cure is a 
method of treatment of great value. It is essential for its successful 
employment that it be modified to suit the needs of the individual case: 
if employed as a set mould into which every case is to be forced, it will 
frequently do harm. Often the best results are achieved by associating 
certain features of the rest-cure with out-door exercise, such as walking 
or carriage-riding. 

The principles of the rest-cure are absolute rest, forced feeding, and 
passive exercise. Absolute rest is often prescribed by the physician 
without being sufficiently definite and insisted upon. When it is de¬ 
sired to apply it most strictly, it should be clearly explained that the 
patient is not to be allowed to get out of bed even to pass urine or 
fseces, nor to feed himself or herself, nor perform any act of the toilet 
whatsoever. The rest also must be for the mind as well as for the 
body, and it is essential that the patient be isolated. In obstinate, 
severe cases of neurasthenia complete and absolute isolation is a sine 
qua non, and especially when there is a decidedly hysterical element is 
it necessary to separate the patient entirely from her friends. Under 
these circumstances there must be a well-trained nurse who is person¬ 
ally agreeable to the patient. The confinement would be very irksome 
to any except the most exhausted patient were it not for the daily visit 
of those engaged in the treatment. To provide further against ennui , the 
nurse should be a good reader, so that under the definite instructions of 
the physician she can occupy a certain portion of the time in reading to 
the patient. 

In order to maintain the functions of the skin, the patient should be 
well sponged with hot water in bed every morning after breakfast. A 
strong solution of salt, or, better, sea-brine, is to be preferred to simple 
water, and frequently it may be followed by the use of alcohol. In 
very feeble cases the alcohol may be employed alone. I have seen 
very good effects from momentarily rubbing each portion of the skin 
with ice just after bathing. When rubbing with ice is practised, the 
bath should be hot. 

In giving the bath the patient should be stripped, and lie between 
blankets, so that exposure of the whole body is avoided while each part 
is thoroughly washed. No exertion on the part of the patient should be 
allowed. Women should not be permitted to arrange their own hair. 

The question of feeding is one of great importance, and requires the 
utmost care and attention from the physician. The end to be attained 
is to feed the patient as much as can be digested, but not to overfeed 
and derange the digestion. Food should be given at intervals of two or 
three hours, and must be both light and nutritious. It should, at least 
at first, consist largely of milk, except in those rare cases in which that 
fluid does really disagree with the stomach and is not merely thought 


42 


THE TREATMENT OF SYSTEMIC STATES. 


to do so. The milk should be skimmed or given in the form of koumiss. 
Beef juice and other concentrated meat essences are valuable as stimu¬ 
lants, and may be used especially as the basis of soups. Various farina¬ 
ceous articles of food may be added to them: if an egg be broken into 
the concentrated bouillon or beef essence just as it ceases boiling, a nu¬ 
tritious and to many persons palatable dish is obtained. When consti¬ 
pation exists, oatmeal porridge, Graham bread, and fresh or dried fruits 
may be allowed if readily digested by the patient. In order to give 
an idea of a general plan of the dietary, the following schedule of the 
daily life is given. It must be altered from day to day, so as not to 
wear} 7- the patient by its monotony. Such a schedule should always be 
put in the hands of the nurse, who should be required to follow it 
strictly. Success will in a great measure depend upon the practical 
skill and tact of the physician in his adaptation of the diet to the indi¬ 
vidual requirements of the case: 

8 a.m. Bolls or toast; cocoa or weak coffee, or roasted wheat coffee; 
beefsteak, tenderloin, or mutton-chop. 

9 a.m. Bathing. 

11 a.m. Oatmeal porridge, with milk, or else a pint of koumiss. 

12 m. Massage. 

2 p.m. Dinner: bouillon with or without egg; beefsteak, rice, roast 
white potatoes; dessert of bread-pudding, blanc-mange, or similar fari¬ 
naceous articles of diet. 

4 p.m. Electricity. 

5 p.m. Milk toast. 

9 p.m. Half a pint of skimmed milk or koumiss. 

In many cases the patient at first can take very little food, and it is 
frequently best to begin the treatment with an entirely liquid diet, 
giving milk ever}* two hours, or some nutritious soup, with milk or 
plain farinaceous food, and only after a time gradually accustoming 
the patient to solid food. Not rarely a prolonged treatment by the 
so-called milk diet is of avail. The rest-cure is, indeed, largely based 
upon a careful regulation of the food. 

Passive exercise is to be obtained by the use of electricity and mas¬ 
sage, the object being to get the effects of exercise upon the nutrition 
and circulation without the expenditure of the patient’s nerve-force. 
By the use of electricity muscular contractions are secured that simu¬ 
late those which are voluntary, and more or less thoroughly replace 
them. 

The faradic current is alone used. It is applied in two ways: first, 
to the individual muscles; second, to the whole body. The seances 
should be daily, the operator beginning at the hand or the foot, and 
systematically faradizing each muscle of the extremities and the trunk. 

The slowly-interrupted current is generally preferable, but advan¬ 
tage is sometimes gained by varying the rapidity of the interruptions. 
The general rule is to select that current which produces most muscular 


EXHAUSTION AND NEURASTHENIC CONDITIONS. 


43 


contraction with the least pain. The poles should be applied succes¬ 
sively to the motor points of the muscles, so as to contract each firmly 
and thoroughly. This process should occupy from thirty to forty min¬ 
utes. The electrodes are then to be replaced by large sponges well 
dampened with salt water: one of these should be put at the nape of 
the neck, and the others against the soles of the feet, and a rapidly- 
interrupted current, as strong as the patient can bear, should be sent 
through the body for twenty minutes or half an hour. It is unneces¬ 
sary for the physician to remain during this time. In some cases the 
electrical programme may be varied so as to get a local stimulant action 
from the general current. Thus, when digestion is enfeebled and the 
bowels are costive, for a portion of the time one of the sponges may 
be placed upon the epigastric region. In women, when there is great 
abdominal and pelvic relaxation, one pole may be placed high up in the 
vagina. I have seen old-standing prolapsus cured in this way. 

The principle of rest-cure for the relief of exhaustion has a very 
wide application. Thus, in the treatment of acute diseases, such as 
typhoid fever, in which death results from exhaustion, it is of the ut¬ 
most importance that absolute rest be prescribed very early. Before 
the diagnosis can be certainly established, and when there is merely a 
suspicion of typhoid fever developing, the patient should be put to bed, 
and should not be allowed to get out for any purpose. One great 
object of nursing is the saving of the strength of the patient and the 
prevention of exhaustion by disturbance. Mere uncleanliness, a low 
voice to a deaf patient, a loud, high-pitched voice to one whose hear¬ 
ing is acute, failure to understand quickly the whims and caprices of 
a sick man or woman, are tormenting things, which may take away 
the rest and even destroy the life of a patient. It is almost equally 
essential that all fussiness be avoided. The nurse who is continually 
asking the patient whether he will have this or that, or wants this or 
that, or is shifting the blinds, or fixing the furniture, or moving about 
unnecessarily, may not only be disagreeable, but may do great harm. 

In applying the rest-cure to the treatment of the individual case, it 
must be remembered that the system is based upon certain principles, 
and that these principles are frequently, in the individual case, best 
carried out by a modification of the details of the plan which I have 
given. Not rarely advantage is obtained by daily sending the patient 
out carriage-riding, or even from taking walking exercise once a day. 
In other cases the rest-cure may be very advantageously combined 
with more protracted out-door life and exercise, the patient being 
required simply to pass twelve, fourteen, or sixteen hours out of the 
twenty-four in bed and the rest in the open air. It is impossible, 
within moderate scope, to describe all the modifications of the method 
which will occur to the skilful physician. 

The time of continuance of the rest-cure varies greatly: even in 
extreme cases the patient should be allowed to sit up at the end of 


44 


THE TREATMENT OF SYSTEMIC STATES. 


six or at most eight weeks, and in many instances three weeks of se¬ 
clusion is all that is absolutely essential. The period of convalescence 
requires care. An attempt to return rapidly to the performance of 
household duties or to the ordinary labors of life will usually dissipate the 
acquired strength, and for the gain to be permanent it is in most cases 
necessary that the patient be sent to some quiet sea-shore, mountain, or 
country resort, in order by out-door life and gradually increasing exer¬ 
cise to harden into permanent form the flesh and strength which have 
been laboriously gathered. 

TREATMENT OP CORPULENCE. 

For the reduction of excessive corpulence a number of plans of 
treatment have been developed, many of them known by the name 
of the inventor or of the first patient. Among these is the so-called 
Bantingism, which was originated by Dr. Harvey, of London, for the 
relief of a Mr. Banting. The essential feature of Bantingism is the 
withdrawal of carbohydrates from the food and the living upon more 
or less rigidly nitrogenous diet. If the view held by some modern 
physiological chemists be correct, that nitrogenous food is in part so 
split up in the system that fat is formed from it, it is plain that even 
by an exclusively nitrogenous diet we do not entirely cut off the sup¬ 
ply of fat-material; yet experience shows that in the great majority 
of cases under such restriction of diet the fat does disappear, and 
generally with great rapidity. The practical question is, however, 
whether the desired end is best obtained by such rigid diet; and 
probably few practitioners who have thoroughly tried the plan are 
entirely satisfied with it. It has been accused of producing Bright’s 
disease, and it is certain that the excessive use of nitrogenous food 
does throw a strain upon the renal organs. This danger is, however, 
to my thinking, too remote to be of great practical importance, except 
in so far as it should lead the physician to examine occasionally the 
urine of the dieted patient, and, if albumen should appear, to change 
the treatment. 

More valid objections are the chilliness and weakness from which 
patients often suffer although the albuminous food is allowed in large 
amount, and the ever-increasing repugnance to meats, which in some 
cases becomes almost unconquerable. This chilliness and the longing 
for hydrocarbons seem to be based upon an actual need of the system 
for fresh hydrocarbon, and Professor Yoit affirms that he has seen dogs 
fed upon an exclusively albuminous diet perish of inanition. More¬ 
over, in some cases of Bantingism the stomach rebels altogether against 
flesh-digestion, and severe dyspeptic symptoms develop, while, if there 
be any tendency whatever to gout, arthritic symptoms rapidly become 
severe. As an exclusive, final method Bantingism is not satisfactory. 

A dietetic treatment of corpulence which has been much practised 
in Germany is that devised by Professor Ebstein, and generally known 


TREATMENT OF CORPULENCE. 


45 


as the Ebstein method. It is simply a modification of the plan em¬ 
ployed by Dr. Harvey. Three meals a day are allowed, the routine 
being as follows: 

Breakfast.— Two hundred and fifty grammes of tea without sugar 
or milk; fifty grammes of white bread, with plenty of butter. 

Lunch. —Fatty soup, made from a marrow-hone; one hundred and 
twenty to one hundred and eighty grammes of flesh, containing much 
fat; some vegetables; stewed fruit without sugar; two or three glasses 
of wine. Later in the afternoon, one cup of tea without milk or sugar. 

Evening.— One cup of tea without milk or sugar, thirty grammes 
each of bread and butter, one egg, or a piece of fat ham or fat roast 
meat, or cheese, and fresh fruit; no alcohol. 

As the result of living upon this diet, Ebstein, who was his own first 
patient, lost in the course of the year eighteen German pounds. He 
states that the use of the fat produced a sense of satiety, and stilled 
the thirst and carbon-longing which are often so severe under Bant- 
ingism. The originality of the Ebstein cure seems to consist in the 
relief of the hydrocarbon appetite by fat. It is largely employed in 
Germany, and has even been tried with asserted good results upon 
animals, especially upon the pug-dogs of the German dowagers. It is 
stated that Vogel, in Stuttgart, reduced a dog five hundred and eighty- 
five grammes in a week by administering weekly three pounds of oat¬ 
meal, and at first one hundred grammes of fat, afterwards increased to 
one hundred and thirty grammes. 

Another method of treatment of obesity which has given rise to 
much discussion originated with Professor Oertel, who in 1875 was in 
a condition of excessive corpulence in which great shortness of breath, 
marked failure of heart-power, inability of exertion, and increasing 
dropsy appeared to portend death. After failure of treatment by the 
most renowned physicians of Munich, Professor Oertel devised the 
so-called u Oertelischen-Kur ,” known more commonly, perhaps, as the 
“ Schweninger-Kur." The essential features of this plan are regulation of 
the diet, almost complete abstention from water, and increasingly violent 
exercise, especially as obtained by systematic mountain-climbing. 

Without discussing at present the various plans for the treatment 
of corpulence which have been devised, it is sufficient to draw from 
them the conclusion that the rational treatment of this bodily condition 
consists in the regulation of the diet and exercise, and that it is possi¬ 
ble in most cases by such regulation to bring about the desired result, 
unless the tendency to excessive fat-production is an inherited constitu¬ 
tional peculiarity so strong that it can only be kept in check and cannot 
be entirely overcome. 

The diet problem naturally divides itself into four parts for study: 
first, the quantity of food to be allowed; second, the relative amount 
of flesh, starchy hydrocarbons, and fats; third, the amount of water; 
fourth, the amount of alcohol. 



46 


THE TREATMENT OF SYSTEMIC STATES. 


Of these sub-problems the last is so easily and plainly solved that it 
may be settled at once. Alcohol is never necessary to a well-fed, healthy 
man. It is a pure hydrocarbon, capable of saving fat. Its excessive 
use, especially in the form of beer, is a common cause of corpulence, 
and theoretically it should be denied entirely to corpulent patients. If, 
however, previous habits have been such that its use cannot be stopped 
abruptly, it should be withdrawn as rapidly as possible. It should 
never be taken in the form of malt liquors, but in that of a diluted 
spirit or of light wine. In cases where strenuous exertion is to be 
made, a little sour wine added to the small amount of drink allowed 
the patient is often of service in alleviating thirst and in stimulating 
the heart. 

The regulation of the quantity of food is a matter of the greatest 
importance, and should be attended to before anything else. In his 
Advice to Fat People (a little book published anonymously in England), 
a captain of a British regiment states that he had for thirty-eight years 
suffered from obesity, having been at birth an enormous freak of nature, 
clearly intended for twins. At eighteen he weighed two hundred and 
fifty-two pounds. Banting taught that quantity may be fairly left to 
the natural appetite provided the quality be strictly regarded, but the 
captain asserts that quantity is even more important than quality; and, 
acting upon this, in ten months he reduced his weight one hundred and 
seventeen pounds and his girth eighteen inches by adhering closely to 
the following dietary: 

6 a.m. One pint of black coffee and one ounce of coarse brown 
bread or biscuit. 

9 a.m. Four ounces of lean meat, three ounces of brown bread or 
biscuit, and half a pint of coffee. 

2 p.m. Six ounces of lean meat, three ounces of brown bread or bis¬ 
cuit, six ounces of green vegetables, and half a pint of any fluid except 
ale, effervescing wines, or aerated water, followed by half a pint of coffee.. 

6 p.m. Half a pint of coffee. 

At supper two ounces of brown bread or biscuit, and a couple of 
glasses of sherry or claret. Fruit ad libitum , liquorice powder pro re nata. 

The average amount of food required by the human adult is gener¬ 
ally acknowledged by competent authorities to be about as follows: 

Albuminous materials. Fat. Starchy hydrocarbons. 

30 drachms. 25 drachms. 92 drachms. 

The analysis of the ration allowed Mr. Banting, given by Dr. Carl 
Zahn, shows that he took daily— 

Albuminous material. Fat. Starchy hydrocarbons. 

43 drachms. 2 drachms. 5.25 drachms. 

while the Ebstein ration contains— 


Albuminous material. 

25.5 drachms. 


Fat. 

21.25 drachms. 


Starchy hydrocarbons. 
11.75 grammes. 


TREATMENT OF CORPULENCE. 


47 


On examining the Ebstein ration it will be seen that it furnishes a 
much smaller amount of hydrocarbons to the system than is required 
for its support, so that the Ebstein method is only a mild Bantingism. 
In the treatment of the individual case of excessive corpulence it is 
essential that the physician study the individual patient,—his present, 
past, lilies and dislikes, constitutional tendencies, etc.,—and then prepare 
a special diet-list in accordance with the results of this study. General 
directions in regard to the amount of food to be taken are not usually 
sufficient when the condition of corpulence is pronounced or obstinate. 
The daily ration must be accurately weighed. Almost always it will be 
found that the patient has been eating much more than was necessary. 
Care should be exercised in immediately reducing the amount to the 
ration laid down as the average one, and as the case progresses the 
standard ration can be departed from in the direction of increase or 
diminution according to the individual needs. It is certain that some 
individuals require more food than do others for the support of the 
system, and this, independently of any question of habits of activity 
or of weight. The too rapid reduction of the weight is not to be 
desired. The aim is a moderate, steady reduction. The allowance of 
food should be increased or diminished according to the rapidity of the 
loss of weight, which should be ascertained weekly by careful weighing 
on the same scales, the patient being dressed in the same clothing. 
The ration should approximate in character that laid down by Ebstein 
rather than that of Harvey. Thus, there should be only a moderate re¬ 
duction of the fats and hydrocarbons below the normal amount, and only 
a moderate increase of the nitrogenous food. When the excess of fat 
in the system is not very great and yields readily, it may not be neces¬ 
sary to weigh the food, and the partial withdrawing of hydrocarbons 
may be sufficient. As a foundation upon which the physician may 
arrange his bill of fare, the following table, originally compiled by 
Dr. Zahn, is appended. It gives the approximate amount of food- 
material in various common articles of diet in parts by weight. 


Food. 

Water. 

Albumen. 

Fat. 

Hydro¬ 

carbons. 

Mean of ten different kinds of simple soup 

91. 

1.1 

1.5 

5.7 

Mean of ten rich soups. 

83.2 

2.6 

3.2 

9.7 

Boiled beef, lean, from young heifer . . . 

66.5 

28.4 

1.3 


“ “ fat, “ “ “ ... 

49. 

38. 

12.1 


Beef from steers and oxen, boiled. 

56.8 

34.2 

7.5 

0.4 

“ “ “ “ “ roasted .... 

59. 

38.2 

1.7 


Roast meats, including beefsteak, game, 
birds, etc., reckoned as an average . . . 

58. 

38.2 

2.7 


Veal, roasted. 

78. 

15.3 

5.2 


Fricasseed veal, with fat and milk .... 
Fat roasted pork or goose. 

57. 

22.3 

10.4 

l’o. 

40. 

34.6 

24.2 


Smoked ham. 

59.73 

25.08 

8.11 


Boiled fish. 

74.20 

22.10 

0.60 

0.70 

Shell-fish. 

80.97 

17.09 

0.34 

• . 

Mean of seven different kinds of meat-foods 

44.20 

8.70 

15. 

28.9 

Potatoes, roasted. 

72.40 

1.90 

3.30 

2L20 






















48 


THE TREATMENT OF SYSTEMIC STATES. 


Food. 

Water. 

Albumen. 

Fat. 

Hydro¬ 

carbons. 

Potatoes, as salad. 

73. 

2.10 

3.20 

21.80 

“ boiled. 

70. 

1.80 

3.10 

24. 

Salad, green. 

94.2 

1.40 

2. 

2.2 

Vegetables in general, average*. 

62.2 

6.40 

1.40 

30. 

White bread. 

40.45 

6.15 

0.44 

51.12 

Black bread. 

31. 

11. 

, , 

57. 

Dried fruit . 

1.18 

13.31 

3.18 

81.08 

Milk. 

87.42 

3.41 

3.65 

4.81 

Cream. 

65.51 

3.61 

26.75 

3.52 

Buttermilk. 

90.27 

4.06 

0.93 

3.73 

Butter. 

14.49 

0.71 

83.27 

0.58 

Cream cheese . 

35.50 

17.44 

40.80 

5.21 

Lard. 

0.70 

0.26 

99.04 

. , 

Sugar . 

2.16 

0.35 

. . 

96.32 

Vinegar.J. 

94. 

. . 

. . 

0.4 

One egg, estimated not by percentage, but 




0.053 

by amount in average egg. 

8.253 

1.43 

1.353 

Tea. 

97.9 

0.3 

. . 

0.6 

Coffee. 

94.7 

0.18 

0.52 

1.4 

“ with milk. 

93.3 

1.60 

2.20 

1.6 

Chocolate with milk. 

89. 

3.7 

3.6 

3.8 


The question of the water-allowance is a serious one. The chief 
hardship of the dieting is, to many Americans at least, the withdrawal 
of the water-supply, and the patients continually ask whether water 
makes fat. So far as our present chemical knowledge goes, water does 
not make fat. Some German writers have asserted that water, by 
causing an increase of the blood-volume, delays circulation in the small 
capillaries, and thereby facilitates the change of food-fat into body-fat. 
This is, however, a pure theory, resting upon no established founda¬ 
tion, and probably incorrect. There is, in truth, no sufficient scientific 
reason for the withdrawal of water from the diet-list of persons who 
are suffering from obesity, as is well shown in a critical review on the 
role of water in nutrition by Callamand (.Archives Gen. de Med., vol. 
xvii., 1886, 711). Nevertheless, since the days of Cselius Aurelianus 
(De Morbis Chronicis, ed. Amsterdam, 1709), in almost all the plans of 
reducing flesh recommended by physicians or employed by practical 
trainers, abstinence from water has been an important feature. This 
concord of practice is not to be forgotten, and it is possible that em¬ 
piricism has in this direction outrun science, so that, while extreme 
measures seem unnecessary, it is probably in many cases essential to 
moderate the daily allowance of water. 

"When the symptoms of disturbance of the circulation are very great, 
and especially when the excessive drinking of beer or other liquid has 
caused a great excess in the bulk of blood in the body, abstention from 
fluids may be imperative in order that the volume of the blood may be 
reduced and the strain upon the circulation lessened. In Professor Oer¬ 
ters case the state of affairs just spoken of seems to have existed, and it 
is almost inevitable that he should magnify the importance of dryness. 


♦Vegetables exclusively American, such as tomatoes and green corn, are not included in 
this analysis. 

































TREATMENT OF CORPULENCE. 


49 


When a gouty diathesis exists, the withdrawal of water is attended 
with danger, an overplus of liquid being apparently necessary to wash 
out from the blood, through the emunctories, the arthritic products. 
That this danger is not a mere theoretic one is proved by the fact that 
Dr. Kirsch ( Lond. Med. Rec., August 15, 1887) has reported cases in 
which violent attacks of gout have followed the dehydrating treatment 
of obesity. He has also seen colic from gall-stones occur for the first 
time after such treatment, and further states that not rarely the loss of 
weight which he believes is produced by the withdrawal of water is 
accompanied by a marked muscular weakness. 

The amount and form of exercise to be prescribed in any case of 
obesity depend upon the peculiarities of the patient and his surround¬ 
ings. Certain general principles, however, apply to every case, and if 
these are observed the details may vary indefinitely. First, the exer¬ 
cise must be regular and persistent; second, it must involve not only 
certain muscles, but all the muscles of the body; third, it must be suf¬ 
ficient in amount to produce an effect,—it should always, indeed, be 
carried as far as is possible without the production of exhaustion; 
fourth, it must be sufficiently active to produce sweating, which, in 
many cases, may be encouraged by the use of warm clothing during 
exercise. Professional trainers, indeed, attach much importance to 
sweating as a means of reducing weight. It probably acts not only 
by dehydrating the body, but also by hastening the elimination of par¬ 
tially used-up materials, and is particularly indicated when there is any 
gouty tendency. 

In selecting the form of exercise care should be taken that it be as 
little irksome as possible to the patient, and if it can be made a pleas¬ 
ure much will be gained. Professor Oertel, in his own case, practised 
mountain-climbing, and he attributes to it great superiority over other 
forms of exercise. There can be no disputing the effectiveness of 
mountain-climbing as a means of exercise. That it accomplishes, how¬ 
ever, all that Professor Oertel claims for it is exceedingly improbable. 
He asserts, as the result of experiments, that mountain-climbing causes 
increased blood-pressure, with vascular dilatation and lowering of the 
arterial tension. I think that few physiologists will believe that it is 
possible to have increased blood-pressure with increased vascular dilata¬ 
tion and lowered arterial tension, the dominant factor in the production 
of blood-pressure being the vascular dilatation. The sphygmometer 
can scarcely be considered an instrument of precision. Although moun¬ 
tain-climbing cannot be looked upon as a specific, it is, when suitable 
opportunities are afforded, a very good form of exercise, because it 
can be so readily regulated and may be made to combine pleasure 
with work. At first the patient may ascend the same slope day after 
day, each time getting a little higher than the day before; but as the 
cure progresses, different excursions should be made, to add interest 
to labor. In America high attractive mountains are not so accessible 

4 


50 


THE TREATMENT OF SYSTEMIC STATES. 


as in Europe, and other forms of exercise may well be substituted. A 
foot-exercise with whose flit-destroying tendency every trainer is famil¬ 
iar is running. The influence which it has upon heart and lungs does 
not differ from that of mountain-climbing, and, if there be any truth in 
the teachings of Oertel as to the value of pulmonic and cardiac gym¬ 
nastics, running ought to be of especial value when the heart and lungs 
are giving evidences of being specially affected by the fat-accumulation. 
Boat-rowing, or even canoeing, may serve the purpose of the fat man. 
Wood-sawing is largely employed in some European anti-fat sanita¬ 
riums, and is undoubtedly efficient. It can be very readily graduated 
by requiring one or two sticks more to be sawn each successive day. 
Gymnastic exercise, lifting of weights with pulleys, etc., may be em¬ 
ployed, and even horseback-riding may be made efficient. Professor 
Oertel further believes that mountain-climbing affords a method of 
gymnastically training the heart and lungs which may be of the greatest 
service in the treatment of a weak heart. It must, however, be re¬ 
membered that the heart is in an essentially different position from the 
voluntary muscle. The muscle loses its power through want of exer¬ 
cise, and is brought back from its soft, flaccid condition by exercise. 
Weakness of the heart-muscle, on the other hand, is practically never 
the result of lack of exercise of the heart, but is due to the accumula¬ 
tion of fat about the muscular fibres, or to degeneration of the muscle, 
to exhaustion from overwork, or to the presence of some poison in the 
blood. If the cardiac weakness be connected with a fatty change in 
the muscle which is the result of general fatty infiltration of the body, 
the removal of such fat-infiltration will be accompanied by improvement 
of the muscle of the heart, which improvement of the heart-muscle 
may probably be aided by cardiac exertion. If, on the other hand, the 
cardiac weakness is the result of overstrain or of a true fatty degener¬ 
ation, the probabilities are that it will be increased rather than dimin¬ 
ished by cardiac exertion. That these considerations are not merely 
theoretic is shown by the fact that Dr. Kirsch asserts ( Lond. Med. JRec., 
August, 1887) that in a number of cases he has seen violent attacks of 
acute exhaustion of the heart with enormous increase of the frequency 
and irregularity of the pulse and cardiac asthma, and in some instances 
even sudden death, result from mountain-climbing directed by skilful 
physicians in accordance with the teaching of Professor Oertel. 

In all cases the exercise should at first be gentle and should be 
increased very carefully. Thus, mountain-climbers or runners should 
at first stop every few feet, to allow heart and lungs to recover them¬ 
selves. It is sometimes very difficult to decide whether the heart is in 
a condition of fatty degeneration or simply in one of fatty overload¬ 
ing, and in doubtful cases the utmost caution should be exercised by 
the practitioner. 

There are not a few robust men who have reached middle life and 
begun to suffer from very excessive corpulence, the result of habitual 


LITHIASIS. 


51 


overeating and underexercise. To such persons I can from personal 
experience recommend work in the wilderness, especially a tour in the 
Rocky Mountains or in the wilds of Canada or of Texas. If the 
expedition be arranged to be out for two or three months, so that the 
only food that can be carried is flour, coffee, and salt pork, and the horse¬ 
back-riding or marching be to the limit of endurance, there will be 
little need of a scientifically controlled diet or of an exercise-programme. 
I have found that the August sun of southwestern Texas or of New 
Mexico is a very efficient sweat-producer, and even in the cool atmos¬ 
phere of the upper Rocky Mountain regions a cure will almost always 
be effected. The daily labor of travelling in a canoe in a wilderness 
like that of Maine or Canada, the long hours of paddling or rowing, 
the assistance to the guides in camp-making, are in many eases suffi¬ 
cient to reduce the overstout man to a better condition; and if he will 
manfully shoulder his loads at portages, carrying packs of forty or 
fifty pounds through swamp or forest, up hill and down hill, for some 
hours daily, he will find little need to haunt sanitariums. 

LITHIASIS. 

Although the gouty diathesis is one of the most frequent of bodily 
complaints in middle-aged persons of the upper class, and an enormous 
amount of study and research has been devoted to the determination 
of its dietetic treatment, yet no positive scientific knowledge exists 
for our theoretic guidance. This is the fault of the pathologist rather 
than of the therapeutist. The ultimate nature of the gouty diathesis 
remains as much unknown as the ultimate nature of syphilis. We are 
therefore forced to rely upon empirical clinical experience, and even 
this is not yet entirely satisfactory. Thus, one of the most recent Eng¬ 
lish authorities, Dr. J. Milner Fothergill, states, in speaking of the diet in 
chronic gout, “ Fat is in all forms desirable, especially butter and bacon 
fat,” while the German professor J. Bauer, writing in 1883, says, “ In 
the opinion of most observers, the food of the gouty should contain as 
little albumen as possible, in order that the fewest products of its 
imperfect oxidation should be retained in the system, and also little 
fat, since this by fixing the oxygen would tend to hinder the oxidation 
of the albuminates.” In the present resume of the subject I shall avoid 
any theoretic discussion of the nature or causes of the gouty diathesis, 
as well as any statement of the opinions of authorities, and shall simply 
give my own views as based upon wide reading and much experience 
in the treatment of gouty patients. 

In the hygienic treatment of gouty patients it is essential that 
exercise be taken systematically and with regularity. If circum¬ 
stances permit, prolonged moderate exercise in the open air (such as 
may be obtained by horseback-riding, rowing, hunting, etc., or even 
by walking) is to be preferred. Gymnastic or house exercises may 
very well be substituted for this out-door work under special circum- 


52 


THE TREATMENT OF SYSTEMIC STATES. 


stances. The form is not a matter of much importance, provided the 
exercise involves the whole muscular system. The amount of exercise 
must be graduated to the needs of the individual case, different per¬ 
sons having no more the same measure of physical strength or the 
same needs for physical work than have different measures the same 
capacity. The endeavor must be always to push the exercise until 
it produces distinct physical weariness, and a better effect will usually 
be obtained if the exertion be sufficiently violent to cause free sweating. 
For the robust, hard muscular labor prolonged through many hours 
maybe necessary; while in the feeblest subjects it maybe essential 
to begin with passive exercise associated with the least possible active 
exercise; but day by day the physical exertion can be increased, and 
the results of systematic training in anaemic, feeble, gouty persons are 
sometimes astonishing. 

Gouty patients may, for the purposes of dietetic discussion, be 
arranged in three classes: first, those who are robust and vigorous; 
second, those who with a distinct feebleness of constitution and slug¬ 
gishness of habit have a marked tendency to the accumulation of fat; 
thix*d, those whose nutrition and genei*al vital foi’ces ai’e habitually on 
a low level. 

In robust gouty persons it is essential that the quantity of food be 
lessened: such patients should be taught to l’ise habitually from the 
table with the appetite not thoi’oughly satisfied. In the second class 
of patients some conti*ol over the appetite is not rarely impei*ative, 
while in the third class of patients it is often equally essential to 
administer food beyond the cravings of the stomach. As individual 
cases occur gi’ading all the foi’ms of the gouty diathesis insensibly one 
into the other, the i*egulation of the quantity as well as of the quality 
of the food becomes a matter to be adjusted to the individual case. 
Thei’e ai'e cei'tain articles of food which should be denied to all gouty 
subjects. Fii-st of these in the list I would place cane-sugar. The 
manifest effect of overindulgence in cane-sugar in the lithamiic diath¬ 
esis is probably not dependent upon any influence which it exerts 
on the genei’al system, but upon the ease with which it undei'goes 
fermentation in the alimentary canal and gives rise to' acid px*oducts. 
Acid fruits, including the tomato and American strawbei’ries, are also 
to be avoided by all gouty subjects, while non-acid fruits, if l'ipe, are 
almost invariably of great service and should be taken freely. The 
harm done by acid fruits is largely due to their irritant influence upon 
the digestive apparatus; and the suggestion of Dr. Fothergill that such 
fruits can be made wholesome by the addition of an alkaline carbonate 
is pi'obably cori-ect. The practical obstacle to carrying out the sugges¬ 
tion is the difficulty of accurately adjusting the amount of the alkali 
so as to avoid on the one hand lack of neuti'alization and on the other 
imparting the alkaline taste. 

In gouty patients of the first class the albuminous principles of the 


LITHIASIS. 


53 


food should be much decreased, but clinical experience proves that the 
form in which the albumen is taken is not unimportant. Eed meats 
are especially to be denied; white meats—except pork—and fish with 
eggs and milk are to form the main staples of animal food. The 
chicken is much preferable to the tui'key. Game is denied by most 
authorities, but I have never seen any harm from its use. The waste 
muscle-products, such as kreatinin, xanthin, etc., have probably some 
connection with the injurious effects produced by red meats. If this 
be so, strong stock soups, which contain an abundance of these prin¬ 
ciples, ought to be injurious; and I have certainly known of violent 
attacks of gout apparently precipitated by the free use of beef tea, 
beef essence, and other similar stimulant liquids. If soups, therefore, 
are employed, they should be vegetable rather than stock soups. 
Ordinary carbohydrates may be taken in moderation. Green vegeta¬ 
bles, including roots, are especially serviceable. 

The proper dietetic treatment of anemic gouty subjects distinctly 
inclined to corpulence is a matter of difficult determination. The first 
thought would lead the physician to order a reduction in the habitual 
ingestion of albumen; but I have certainly known very good results 
produced in patients of this class by lessening very decidedly the 
carbohydrates in the food. When this is done, the albuminous inges¬ 
tion must be increased rather than decreased, in order to support the 
system. In many of these cases, however, it will be found that the 
patient habitually takes an overplus of food, and much good may be 
achieved by lessening the quantity: in such patients the carbohydrates 
can be largely withdrawn and the habitual ingestion of albumen not 
increased. It is especially in patients of this class that the sagacity 
of the physician in modifying the diet to suit the needs of the indi¬ 
vidual will meet with reward. My own plan has been in doubtful 
cases to make tentative alterations of the diet,—to regulate the quan¬ 
tity of food, withdraw carbohydrates, and order the albuminous nour¬ 
ishment to be taken chiefly in the form of fish, white meats, eggs, and 
milk. If the patient improve, the diet is evidently suitable for the in¬ 
dividual case; if there be no improvement, or if there be aggravation, 
the diet can be at once altered. 

In anremic, impoverished, gouty subjects the best results are not 
rarely to be achieved by the employment of generous diet combined 
with the moderate use of alcoholic liquors. In selecting the drink, 
malt liquors and acid wines are to be avoided. My own experience 
is that diluted spirits offer the best form for the administration of 
alcohol. 

In any obstinate gouty case which fails to yield to the ordinary 
regulation of diet the so-called milk diet should be tried. It is not at 
j>resent possible to give any sufficient scientific reason for the alterations 
which are occasionally produced in diseased human systems by the ex¬ 
clusive milk diet. The whole story of changes wrought by the milk diet 


54 


THE TREATMENT OF SYSTEMIC STATES. 


in nutrition we do not know. It evidently, however, has a pronounced 
influence upon primary digestion in the intestinal tracts. It offers 
organic principles in so simple a form as to reduce to the minimum 
the labor of digestion, and probably to relieve greatly the hepatic and 
other similar glandular organs from excess of labor. By virtue of 
the large quantity of water it contains it enormously increases the 
flow of the urine and probably of the secretion of the skin, and in 
some cases is no doubt of great service in washing out excrementitious 
material from the body. Whatever may be the proper scientific ex¬ 
planation of the fact, it is certain that in some cases of gouty diathesis 
and in various other abnormal conditions of nutrition an exclusive 
milk diet is extremely beneficial. Thus, in fatty anasmic subjects a* 
course of two or three weeks of milk diet sometimes alters the nutri¬ 
tion so that afterwards feeding and tonics produce effects which were 
previously not attainable. I have always suspected that in these 
patients there is an underlying gouty diathesis. I have seen cases of 
gouty disease of a chronic and subacute type in which remedial meas¬ 
ures had entirely failed, but which yielded easily, though slowly, to 
an exclusive milk diet. Yery frequently when it is simply intended 
to fatten the patient, or in the combating of the gouty diathesis, milk 
is given largely with other food; but to get the peculiar full effects of 
a milk diet it is essential that the patient abstain at least for a time 
from all other food. After the first two or three weeks stale bread 
may be allowed, then green vegetables, and slowly the patient may 
thus be restored to ordinary diet. In severe cases, however, milk diet 
may be persisted in for weeks, and it is possible for the human adult 
to work laboriously and live exclusively upon milk. In order to afford 
sufficient nitrogenous nutriment, from five to seven pints of milk a 
day must be taken. This amount of milk contains too much fat for 
the needs of the system; it should therefore be skimmed. The so- 
called skimmed milk sold from creameries is not, however, suitable, 
because the fat has been too absolutely withdrawn from it, and because 
it is usually not so fresh as is desirable. The skimming of the milk 
should not be too close. It is essential that the milk be taken at inter¬ 
vals of not longer than two hours, and that it be drunk by sipping 
rather than by gulping, so as to avoid any danger from the formation 
of hard clots in the stomach. When the digestion is good the milk 
may be taken cold. When the digestion is very feeble it should be 
taken hot. But boiled milk should not be employed, as, according to 
the experiments of Drs. Randolph and Dixon, it is of more difficult 
digestion than unboiled milk. The general clinical experience shows 
that it is more actively constipating than unboiled milk. During the 
progress of the milk course constipation is almost invariably present: 
this must be overcome by the administration of drugs. In gouty 
subjects saline laxatives are preferable. 


CHAPTER III. 

CALORIC. 


There are two conditions of the force caloric, spoken of as distinct 
entities, but which are merely relative terms, expressive of the presence 
of an excess or of the absence of the normal amount, or, more strictly 
speaking, normal intensity, of the force. Cold and heat, in connection 
with the human body, respectively mean an intensity of caloric below 
and above 98£° F. 

USE OF HEAT. 

The phenomena of death from cold show that a lack of caloric in 
the body is no less paralyzant of animal functions than is an excess of 
the same force. Evidently the organism was constructed to run upon 
a certain plane of heat, and cannot vary from this without serious 
results. By numerous experiments upon animals I have proved that 
in a cool apartment death rapidly results after section of the spinal 
cord, from falling of the bodily temperature, the animal which in a 
warm room will live indefinitely dying very shortly in a temperature 
of forty degrees. The cause of the inabilit}* of the animal to resist 
external cold after section of the cord is undoubtedly vaso-motor 
paralysis. Normally, the temperature of the interior of the body is 
maintained by keeping an outer layer of partially-cooled tissue between 
the internal organs and tissues and the outer air. When the power of 
contracting the superficial vessels has been lost, the organism can no 
longer maintain this protecting layer, the surface-temperature rises to 
that of the interior, heat is rapidly lost, and the whole body is uniformly 
cooled. 

Yaso-motor paralysis is produced by toxic doses of various reme¬ 
dies, and under these circumstances artificial maintenance of the bodily 
temperature is imperative, forming a very important portion of the 
treatment of all such poisoning. Collapse from any cause is largely 
dependent upon, or, more correctly speaking, largely is, vaso-motor 
palsy; hence in almost all forms of collapse the use of external heat 
is of great importance. 

The late Dr. Chas. Hunter very successfully applied this treatment 
to that form of collapse which follows injuries and surgical operations 
and is known by surgeons as shock. The lack of power of alcoholic 
and other ordinary stimulants in this condition is proverbial. The 

55 


56 


CALORIC. 


pathological state is undoubtedly vaso-motor palsy, the bodily tempera¬ 
ture is much below normal, and the rational treatment consists in the 
hypodermic use of atropine and digitalis and the external employment 
of the hot bath. I believe that this plan of treatment will be found to 
be a most important addition to surgical therapeutics. In the first 
days of post-foetal life the power of resisting external cold is very 
slight, and in many cases of still-born children, or of children whose 
vital powers are almost extinguished at birth, life may be saved by a 
high external temperature, the little waif being kej)t in an air of 98° 
F., and also away from the influence of cold walls and articles which 
would draw off, as it were, the slender store of heat provided by nature, 
radiation being greatly affected by the temperature of surrounding 
objects. 

It is hardly necessary to dwell in greater detail upon the various 
forms of collapse. Enough has been said to illustrate the principle 
that whenever the bodily temperature falls below normal , pyretic treatment 
is demanded. The vigor of the treatment should always be in direct 
proportion to the suddenness and extent of the fall of temperature. 

In regard to the methods of applying heat, it must, in the first 
place, be understood that wrapping in blankets, etc., is able only to 
prevent cooling of the body; that when the animal temperature has 
already fallen it will not suffice at all. The same may be said of air 
heated to temperatures which can be readily obtained or can be con¬ 
tinuously borne by the attendants. Radiated heat is somewhat better, 
and often the use of a brisk open fire is of service. The hot bath is, 
however, the only pyretic remedy that can be relied on. It should 
always be a full bath, in as warm a room as can be procured, and should 
be at a temperature of about 104° F. when the patient is put into it. 
The duration of the bath must vary with the circumstances of the case. 
It should not be less than half an hour, unless the mouth-temperature 
sooner become normal. During the bath the heat of the water should 
steadily be increased as fast as it can be borne if the patient be con¬ 
scious, or, if he be unconscious, until a temperature of 110° F. is reached. 

USE OE COLD. 

The practical study of the use of cold as a therapeutic measure 
naturally arranges itself under three divisions: first, its local use; 
secondly, its very brief general application as a tonic; thirdly, its 
employment in pyrexia. 

LOCAL EMPLOYMENT OF COLD. 

When cold is applied persistently to any part, it acts as a direct and 
very powerful depressant, of varying power according to its intensity. 
It is, therefore, used locally to reduce inflammation , especially when the 
latter is of an active type. In this employment of cold, care must be 


LOCAL EMPLOYMENT OF COLD. 


57 


exercised not to carry its use too far, lest it suspend all nutritive actions 
and interfere with those processes of repair which almost always form 
a part of inflammation. Indeed, it is possible to convert an inflamma¬ 
tion into gangrene by the too energetic employment of this agency. 
Locally, cold is generally applied by means of cold-water compresses, 
irrigation with cold water, and the application of pounded ice, either 
enclosed in india-rubber bags or in bladders, or in form of the ice-poul¬ 
tice. .* It is very doubtful whether the use of “ freezing mixtures” is 
ever justifiable in inflammation. The effects of the cold in individual 
cases are to be judged of by the alterations in the heat and redness of 
the part. The local employment of cold belongs for the most part 
within the province of the surgeon, but the remedy is of gi-eat value 
in certain diseases. In diphtheria and in anginose scarlatina , as origi¬ 
nally insisted upon by Dr. Hiram Corson, very gi’eat benefit may be 
obtained by enveloping the throat over the tonsils with powdered ice 
enclosed in bladders, in pieces of pigs’ intestines such as are used by 
sausage-makers, or in thin india-rubber bags. 

In using cold for the purpose of combating inflammation, the appli¬ 
cation must be kept up until the desired effect is produced. When 
employed intermittently, cold even becomes a stimulant, the reaction 
which follows its first impression being greater than its direct effects. 
Hence the cold douche has been used with asserted advantage as a 
stimulus to sluggish ulcers. 

In internal trunkal inflammations, such as pneumonia and pleurisy , 
the application of cold wet compresses over the diseased organ has 
been employed extensively in Germany. In the hospital at Prague 
every patient suffering from acute pulmonic inflammation is said to be 
treated with cold compresses, and Smoler atfinns that it is very rare 
that immediate relief is not afforded. Niemeyer states that he has 
employed the method in a large number of cases of pneumonia with 
surprisingly good effect, the pain, the dyspnoea, and even the frequency 
of the pulse being usually induced in a few hours. On the whole, the 
evidence in favor of the local use of cold in pneumonia, as well as in 
the croupous catarrhal pneumonia of children (Bartol, Ziemssen), is 
so strong that the repugnance felt to such measures by the profession 
in the United States would seem to be the offspring of unfounded 
prejudices. 

In meningitis the gi’eat value of the application of ice to the shaven 
scalp is undeniable, and in peritonitis I have seen very great relief 
affoixled by the use of cold, as recommended by Abei’crombie, Nie¬ 
meyer, and others. As is the case in pneumonia, warm poultices are 
more generally viewed with favor in pei’itonitis by the profession in 
this country. I have frequently used them with excellent effect, and 
in at least one instance after ice-poultices had been previously em- 


* Made by mixing finely-broken ice with dry Indian meal or fine sawdust. 



58 


CALORIC. 


ployed. In this case the cold applications were at first very agree¬ 
able to the patient, as were the warm poultices afterwards, and the 
good achieved seemed to be in accord with the sensations of the 
patient. It seems to me a good clinical rule to select the ice or the 
warm poultice according to the feelings of the patient. Early in the 
attack, when the fever is high, the ice will generally be the more 
useful. 

Under the head of the local action of cold it is perhaps proper to 
allude briefly to the use of the cold douche as a means of reducing 
splenic enlargements. I have had no experience with the measure, but 
an elaborate experimental and clinical study has led Dr. Fr. Mosler to 
the following conclusions. In the spleen immediate contact with cold 
water produces a very perceptible contraction, which is in direct pro¬ 
portion to the coldness of the water; the application of cold water 
to the abdomen influences similarly but less efficiently the normal 
spleen; the cold douche applied for two or three minutes, and repeated 
at longer or shorter intervals, very perceptibly affects the enlarged 
spleen of intermittent and typhoid fevers, and even of leukiemia. In 
chronic cases the application should usually be made twice a day. 
( Virchow's Archiv, Bd. lvii. p. 1.) 

COLD AS A TONIC AND STIMULANT. 

Almost every one has experienced the exhilaration of the reaction 
which, in a healthy person, follows the sudden dash of a cold shower- 
bath or the plunge into a mass of cold water. The researches of 
Liebermeister, which will be detailed hereafter, prove that a cold 
bath, when of not too long duration, actually increases the oxidation 
of tissue to such a degree as to elevate the temperature of the body. 
When cold bathing is employed as a tonic, the first principle to be 
borne in mind is that the bath should not be too severe or too long 
continued, else it becomes a direct depressant, debilitating and lower¬ 
ing the temperature of the bather. When the subject has sufficient 
vital power to react after the bath, sea-bathing is often of very great 
service, but in debilitated persons it may produce a serious exhaustion, 
partly by the fatigue induced, and partly by the excessive abstraction 
of heat from the body. The cold bath, when not followed by a 
healthy reaction, is anything but a tonic. 

COLD IN PYREXIA. 

The use of cold in fever is no new thing: employed by Galen, used 
not infrequently during the last century, first systematized and insisted 
upon by Currie, cold bathing in fever was brought before the world as 
a really new-born measure by Brandt of Stettin, and received the seal 
of permanent usefulness from the scientific clinical labors of Jiirgensen 
at Kiel. 


COLD IN PYREXIA. 


59 


The consideration of the method naturally divides itself into—first, 
a study of its physiological action; secondly, an investigation as to its 
clinical value; and thirdly, a more particular account of its effect, the 
cases to which it is best adapted, and the method of its application. 
Moreover, there are two distinct forms of pyrexia, which may be 
termed the acute and the chronic, and which are best considered 
separately. 

Acute Pyrexia.— If the following propositions be true, caloric in an 
excess acts as a direct poison to the body, and the phenomena of severe 
acute fever are largely due to the heat itself. The proofs of the 
propositions are given very briefly after them.* 

First. External heat applied to the body of the normal animal, so 
as to elevate the temperature, produces derangement of the nerve- 
functions, of circulation, etc., precisely similar to those seen in natural 
fever; the intensity of the disturbance being directly proportionate to 
the rise in temperature. 

Second. Heat applied locally to the brain or to the heart produces 
in the functions of the organ those disturbances which are familiar 
phenomena of fever, the intensity of the disturbance being directly 
proportionate to the excess of heat in the organ. 

Third. The withdrawal of the excess of heat in fever is followed by 
a relief of the nervous and circulatory disturbances. 

When a dog, cat, or rabbit is shut up in a box heated either by the 
sun’s rays or by artificial means, the temperature of the animal rises, 
and at the same time the pulse-rate becomes pari p>assu more rapid, the 
breathing grows more and more hurried, and the restless, uneasy move¬ 
ments of the victim show the general distress it is suffering. As the 
temperature increases, the nervous disturbance becomes more and more 
apparent; and stupor, coma, partial paralysis, convulsions, and finally 
death by arrest of the respiration, occur. These phenomena sometimes 
come on gradually, but sometimes are developed suddenly. The tem¬ 
perature at which death occurred in my experiments varied in the 
rabbit from 111 0 to 1141° F.; in the dog it was about 111° F. In 
man a similar series of phenomena are developed by exposure to ex¬ 
cessive heat, although, owing to his extraordinary power of cooling 
his body and of protecting it against cold, he is able to bear extremes 
of temperature far beyond the points which would prove fatal to any 
given species of animals. Yet when his body is heated the results are 
the same, as is proved by the terrible mortality of sunstroke. 

To prove the second proposition, I caused hot water to flow through 
pigs’ bladders fitted as a sort of bonnet to the heads of cats and rabbits. 
It is evident that with small animals we can in this way heat the brain 
without heating materially the remainder of the body. It was found 


*Want of space prevents the elaboration of this. The unconvinced reader is respect¬ 
fully referred to the author’s treatise on Thermic Fever, and his Toner Lecture on Fever. 



60 


CALORIC. 


that coma, with or without convulsions, was produced. Sometimes the 
stupor came on gradually, hebetude slowly deepening into coma, but 
in other instances unconsciousness was developed very suddenly. It 
was found that severe nervous symptoms and death were produced 
when the brain reached the temperature which was fatal to the animal 
in the hot box. Without occupying more space, the conjoint labors of 
Dr. T. Lauder Brunton and Dr. C. Liebermeister have proved that the 
accelerated pulse in fever is largely due to the action of the heat upon 
the heart and its nerves: so that the second proposition may be con¬ 
sidered demonstrated. 

In regard to the third proposition, I have frequently taken animals 
out of the hot box perfectly unconscious and plunged them into a 
bucket of cold water, have watched the temperature of the water rise 
while that of the animal fell, and as the bodily heat came towards 
normal have seen the coma disappear, so that within ten minutes the 
at first absolutely comatose and dying rabbit would be skipping about 
on the grass. I have placed a man whose temperature was nearly 
110° F., who was unconscious, with a feeble running pulse of 160 or 170, 
irregular, jerking, slow respirations, and every indication of immediate 
death, in a bath of 60° F., and within a minute and a half have seen 
consciousness partially restored, and in another minute and a half the 
man trying to get out of the bath. What could the bath do to affect 
the man so profoundly and so quickly but withdraw the heat ? That the 
heat was present, and that it was withdrawn, the thermometer proved. 
If the drowsiness had been due to simple congestion of the brain, very 
certainly would the bath, by driving the blood from the surface, have 
increased the trouble. It must be borne in mind that this case is by 
no means unparalleled: similar instances of the good effects of the 
sudden withdrawal of heat in rheumatic hyperpyrexia have been re¬ 
corded by both English and German observers, and recent Continental 
literature is full of reports of the relief of nervous symptoms in various 
pyrexias by the abstraction of heat. 

Finally, as excessive heat is present in fever, as excessive heat, when 
present, is not only able, but is forced, so to speak, by its own attributes, 
to produce disturbance of the functions of innervation and circulation, 
and as the withdrawal of the excessive heat in fever is followed by 
instantaneous relief of the symptoms of disturbed innervation and 
circulation, surely the conclusion is logically inevitable that excessive 
temperature is the chief cause of the other symptoms of fever, and 
that in acute pyrexia threatening life the heat should be withdrawn as 
rapidly as possible by means of the cold bath. 

Chronic Pyrexia .—The effects of a long-continued pyrexia, not suf¬ 
ficiently intense to induce immediate serious symptoms, upon the 
structure of the various tissues, have been elaborately investigated by 
Liebermeister {Deutsches Arch, fur Klin. Med., Bd. i.), who found that 
the liver, spleen, kidneys, voluntary and involuntary muscles, blood- 


COLD IN PYREXIA. 


61 


vessels, and even the nerve-centres, undergo a granular degeneration 
during a continued pyrexia. The lesion was constantly present in the 
bodies of those who had suffered in this way during life, entirely 
independently of the nature of the primary disease. In cases of infec¬ 
tious fever in which the temperature had never been high, this granular 
degeneration did not exist. Previous to the investigation of Lieber- 
meister, Zenker had demonstrated that the muscles undergo a peculiar 
granular degeneration in typhoid and other fevers; and the fact has 
been abundantly attested by later observers. I do not know that the 
observations of Liebermeister as to the occurrence of this lesion in 
non-infectious pyrexia have been confirmed, but I have no doubt of 
their correctness. 

It is evident that in all fever a primary therapeutic indication is 
to reduce the temperature. Of course, if possible, this should be done 
by checking the excessive production of heat; but, unfortunately, this 
often lies out of our power, and we are forced to abstract the heat by 
mechanical means. 

It is a priori impossible to determine what effect upon the produc¬ 
tion of heat the rapid abstraction of it would have, but, from the 
well-known powers of the organism to resist external cold, it seems 
probable that the heat-production would be increased rather than 
diminished by the abstraction of caloric. An experimental study of 
this problem has been made by several observers, but with, unfor¬ 
tunately, different results. Weisflog ( Deutsches Archiv fur Klin. Med., 
Bd. ii. p. 570) has found that the local abstraction of heat by a cold 
sitz-bath causes a rise in the temperature of the axilla, and that in 
fever-patients, unless the sitz-bath is prolonged over twenty minutes, 
no fall of the bodily temperature results. In 1860, Kernig ( Reichert's 
Archiv , 1860) found that a healthy man in a bath of the temperature 
of 28° to 30° C. produces about twice as much heat as normal; in a bath 
of 24° C., about three times as much; and in a bath of 20° C., about 
four times as much. Liebermeister ( [Beobachtungen und Versuche uber 
die Anwendung des kalten Wassers bei fieberhaften Krankheiten, Leipsic, 
1868) found that in a healthy man exposure to cold for a brief period 
of time causes a rise in the bodily temperature, and on extending his 
researches into fever proved that where the external cooling was not 
too powerful or too long continued the same was true of fever-patients. 
From this it follows that the use of external cold stimulates heat- 
production. This, to my mind, has been confirmed by the chemical 
researches upon men of J. Gildemeister ( Virchow's Archiv, Bd. lii. p. 
131), of Dr. Lehmann (Ibid., Bd. lviii., 1873), and of Professor Lieber¬ 
meister himself (Deutsches Archiv fur Klin. Med., Bd. x. p. 89), and by 
those of A. Roehrig and N. Zuntz (Pfluger's Archiv, Bd. iv. p. 66) upon 
animals, all of which show that both in health and in fever very much 
more carbonic acid than normal is eliminated under exposure to cold. 
This would appear to prove that cold baths increase the production of 


62 


CALORIC. 


animal heat. It seems most probable that this is the case; but A. 
Murri believes that he has proved that the cold baths have no such 
influence * At any rate, the investigations of Liebermeister (loc. cit., p. 
134) and others have shown that the first rise of temperature produced 
alike in healthy and in fever subjects by exposure to a moderate and 
not too long continued cold is followed after removal of the cold by a 
fall of bodily temperature of greater or less degree. While, therefore, 
external cold probably first stimulates, it afterwards depresses the pro¬ 
duction of animal heat. The further experiments of Liebermeister 
(.Deutsches Archiv fur Klin. Med ., Bd. x. p. 425) upon the elimination 
of carbonic acid are also in accord with his temperature-study, for he 
found that after the bath the elimination sank below normal, and so 
continued for a considerable period. 

If the cold bath really affects the fever-process, it ought distinctly 
to reduce the excretion of urea. That it has this action would seem to 
be proved by the research of Sassetzky (Virchow's Archiv , xciv. 517), 
who found that the continuous use of the cold bath invariably lessened 
the urinary elimination of nitrogenous material and of the phosphates, 
although it increased the total flow of urine. The subject is, however, 
a very difficult one, chiefly because it is almost impossible to know 
in any individual case what the elimination of urea would have been 
if no baths had been used. Bauer and Kiinstle ( Deutsches Archiv f. 
Klin. Med ., xxiv.) gave to the patients cold baths upon alternate days, 
and found that the excretion of urea was in each case greater on the 
days when baths were used than on those on which they were not em¬ 
ployed. These experiments have been quoted as showing that the cold 
bath increases the excretion of urea, but in Schleich’s investigations on 
the effects of hot baths (. Archiv f. Exper. Path., 1875) the increase of 
the excretion of urea frequently did not show itself until the day after 
the bath. It is probable, therefore, as believed by Schleich, that the 
destruction of albuminous substance in the tissues is not manifested in 
urea-elimination until after twenty-four hours, or, in other words, that 
twenty-four hours are necessary for the completion of the formation 
and the excretion of urea; so that if the baths are used on a Monday 
the urinary solids will indicate their effects not on the same day but on 
Tuesday. If this be correct, the experiments of Bauer and Kiinstle 
are in accord with those of Sassetzky in showing that the cold bath 
lessens the formation of urea in fever. 

During the bath the pulse of the fever-patient usually becomes 
much smaller and harder, and the sphygmographic tracings made by 
Winternitz before and after the use of the cold bath (if tracings of 
this kind can be trusted) indicate that there is after the cold bath 
greatly increased arterial tonus. (See Verhandl. de-s Congr.fur Innere 


* I have never seen the brochure of A. Murri (Del Potere regulatore della Temperatura 
animate, Firenze, 1873). It is abstracted in the London Medical Record, vol. i. 



COLD IN PYREXIA. 


63 


Med., 1886.) It may be that the good obtained by the cold bath is 
really due to a reflex action upon the nerve-centres, and is not entirely 
the result of the withdrawal of the heat.* 

The results of the physiological study of the effects of cold in fever 
may be summed up as follows: During a sufficiently prolonged applica¬ 
tion of cold the bodily temperature falls, although an increased production 
of heat , i.e., consumption of tissue, at first occurs. After the application, 
the bodily temperature continues to fall, or but slowly regains its former 
position: the present evidence at our disposal indicates, but is not sufficient 
to prove, that this slow regaining of bodily temperature is due to a dimin¬ 
ished production of animal heat,—that is, to a decrease in the waste of 
tissue and in the formation of urea and carbonic acid. 

The clinical evidence in regard to the use of cold in fever may be 
looked at in two different ways. Thus, we may consider the assertions 
and results of individual observers who have seen large numbers of 
cases and used the method faithfully, or we may weigh the sum total 
of the experience of all who have written upon the subject. At first 
sight it may appear that the latter is by far the best course to pursue; 
but it must be borne in mind that the treatment is one opposed to the 
ordinary medical prejudices, that its efficient carrying out involves so 
much labor and attention as to be almost impossible to those who dis¬ 
believe in its usefulness, and that those physicians who claim most for 
the method affirm most strongly that to do much good it must be prac¬ 
tised veiy vigorously and steadily. These things being so, it seems 
wisest to look at the evidence from both points of view, and I shall first 
tabulate all the statistics I have been able to collect and afterwards 
discuss the statements of individual observers. 


* Naunyn (Archiv f. Exper. Path, und Pharm., Bd. xviii., Heft 1 and 2, 1884), indeed, 
recently denies that the good achieved is due to withdrawal of heat at all. In his experi¬ 
ments he found that if he maintained proper ventilation, carefully giving food and water, he 
could gradually heat rabbits up to the temperature of 107° and 108°, and keep them at this 
temperature for weeks without their evidencing any inconvenience and without the production 
of any internal lesions. Krishaber was also able to maintain in a dry room 117° F., his own 
temperature reaching 107°, pulse at 85, respiration 35. Naunyn is a very strong advocate, as 
the result of his experience, of the employment of frequent baths in the treatment of fever, 
but believes they act by indirectly reducing bodily waste and increasing renal secretion, 
strengthening the pulse, and stimulating the nerve-centres. L. Schweinburg and C. Poliak 
(Centralbl. f. Gesam. Therap., March, 1887) have found in a series of apparently very careful 
experiments that cold hip-baths notably increase blood-pressure and lessen pulse-rate, while 
hot hip-baths had the opposite effect. Naunyn believes that better results are obtained from 
the use of constant lukewarm baths than from the employment of excessively cold baths. In 
very severe cases, marked by dicrotic pulse and disturbance of the sensorium, the bath treat¬ 
ment, according to Naunyn, should be commenced before the axillary temperature reaches 
103° F., and frequently a warm bath may in such case be given between two cold baths. 
Such a treatment is especially indicated when there is marked delirium, tremor, subsultus 
tendinum, or great restlessness; a warm bath in the evening then seldom fails to produce some 
favorable result. 



64 


CALORIC. 


TABLE SHOWING THE RESULTS OE THE COLD-WATER TREAT¬ 
MENT IN TYPHUS AND TYPHOID FEVER. 


Name of 
Reporter. 

Place. 

Number 

of Cases. 

Mortality, 

Per Cent. 

Remarks. 

Jiirgensen. 

Kiel. 

160 

3.1 

Previously 15.4 per cent. Typhoid fever. 

Petri. 

Laubbach. 

31 

3.2 

Liebermeister. 

Basel. 

1121 

8.2 

Previously 26 to 30 per cent. Treatment 
very rigorous. Typhoid fever. 

Hosier. 

Greifswald. 

71 

7. 

U 

(6 

92 

9. 

Typhus exanthematicus, previously 50 (?) 
per cent. 

Becher. 

Ostpreussen. 

17 

24. 

Typhus exanthematicus, previously, on an 
average, 10 per cent. 

Brandt. 

Stettin. 

479 

3.5 

Private practice. 

Goden. 

(6 

24 

20.8 

Stohr. 

Wurzburg. 

120 

6.6 

Previously over 20 per cent. 

Drasche. 

Vienna. 

40 

10. 

Year before 16.5 per cent. 

Ziemssen. 

Erlangen. 

32 

9.4 

Formerly, with bad cases, 30.2 per cent. 

Stieler. 

Munich. 

226 

5.6 

Formerly 12.15 per cent. 

Pastau. 

Breslau. 

246 

11.8 

Typhus exanthematicus. Without baths, 
mortality 16.5 per cent. 

Popper. 

Prague. 

20 

5. 

Riegel. 

W iirzburg. 

156 

4.4 

Only serious cases included. Almost every 
fatal case came in too late for baths to do 
good. 

Gotz. 

Prague. 

54 

5.5 

Typhoid fever. Other cases treated at the 
same time, expectantly, 15.4 per cent. 

(i 

(6 

50 

18.8 

Typhus exanthematicus. 

Scholz. 

Bremen. 

125 

4. 

Typhoid fever. 

Wunderlich. 

Leipsic. 

155 

7. 

Typhoid fever. Previously 18.1 per cent, 
out of 1178 cases. 

Zaubzer. 

Munich. 

356 

5.6 

Typhoid fever. Previously 17.6 per cent, 
out of 701 cases. 

Bauer. 

« 

87 

7. 

Typhoid fever. Previously 11£ to 16 per 
cent. 

Duchek. 

Vienna. 

60 

28.3 

According to Brandt, this high mortality 
depended upon the treatment having 
been imperfectly performed. 

Krofft-Ebing. 

Rastatt. 

105 

25.7 

Only bad cases. Previous mortality 34 per 
cent. 

Wille. 

Rheinau. 

59 

19. 


Stecher. 

Claje. 

146 

8.2 


Schonheiden. 

Dammartin. 

82 

3.6 

Mild epidemic. 

Pfeifer. 

Weimar. 

58 

5.2 

Leube. 

Ulm. 

47 

19. 

Typhoid fever, among French prisoners of 
war. Baths of moderate temperature 
used. 

Bohm. 

Niederbronn. 

131 

11.5 

Typhoid fever. Military hospital. 

Gersauer. 

Vigy. 

97 

6.18 

Typhoid fever. Mortality on expectant 
treatment 23.91 per cent. 

Drasche. 

Vienna. 

55 

19. 

Typhus fever. 

Merkel. 

Nuremberg. 

41 

2.2 

Typhus fever. 

Loebel. 

Vienna. 

87 

18.4 

Typhoid fever. 


(i 

105 

28.6 

Typhus fever. The treatment in this and 
in the preceding case was not thoroughly 
carried out; the patients mostly receiving 
only three baths a day. 

G16nard. 

Lyons. 

52 

0 . 

Typhoid fever. 

Schmidt. 

Erlangen. 

56 

0.18 

Several fatal cases not counted, because 
not received until the fifteenth day, and, 
therefore, too late to test the treatment; 
they bring the total mortality to 4.14 per 
cent. 

Heubner. 

Leipsic. 

72 

0.14 


Binz. 

Versailles. 

190 

2.1 

Soldiers. Mostly, if not all, typhoid fever. 

Zeroni. 

Mannheim. 

72 

18. 

Soldiers. 












COLD IN PYREXIA. 


65 


TABLE SHOWING THE RESULTS OF THE COLD-WATER TREAT¬ 
MENT IN TYPHUS AND TYPHOID FEVER.— Continued. 


Name of 
Reporter. 

Place. 

GG 

a i 

£ o 

Mortality, 

Per Cent. 

Remarks. 

Valette. 

Edes. 

Jiirgensen. 

Vogt. 

Tripier and 
Bouveret. 

In German 'l 
Military > 
Hospitals. J 

Ibid. Second ) 
Army Corps. J 

Lyons. 

Boston. 

Tubingen. 

Munich. 

f 1877. 

1878. 

1879. 

[ 1880. 

1882. 

1883. | 

21 

32 

220 

221 

481 

2081 

2112 

1741 

2534 

477 

429 

392 

188 

0. 

2.75 

1.8 

2.7 

6. 

7.4 
8.9 

9.4 
8.9 

3.5 

6.5 

3.5 

3.1 

Typhoid fever. 

Typhoid fever. 

All after this in the table are taken from 
Brandt’s article in the Deutsches Med. 
Wochenschri/t, 1887. 


This table is of such a character that a lengthy discussion of it would 
be unnecessary and unprofitable. The failure at Vienna is, by the up¬ 
holders of the method, very justly attributed to an inefficient carrying- 
out, while the apparent high mortality in some other instances is due 
to the facts that the reporters included none but the most serious 
cases, or that the patients were soldiers worn out by the hardships 
and toils of a severe campaign. Moreover, in many cases the cold- 
water treatment was probably not sufficiently rigorous. Dr. Ernest 
Brandt has made a collection of nineteen thousand and seventeen cases 
of fever in which the antipyretic treatment was carried out with more 
or less care, the average mortality being 7.8 per cent. In this mass 
are included typhoid and typhus fever with all forms of primary and 
secondary complications, occurring in all ages, in both sexes, in epi¬ 
demics and in isolated cases, in hospital and in private practice, in civil 
and in military life, during war and during peace. Brandt very forci¬ 
bly objects to these statistics as not fairly representing the results of a 
stringent antipyretic treatment, because in many instances the treat¬ 
ment was not carried out with rigor, and often it was not begun before 
the last stages of the disease. He has made a second series of sta¬ 
tistics, including five thousand five hundred and seventy-three cases, in 
which the treatment was under the direction of a physician who had 
confidence in it: the mortality is 3.9 per cent. These statistics are 
upon so enormous a scale that if it be possible to demonstrate by sta¬ 
tistical arguments the results of any method of treatment whatever, 
it must be considered proved that the cold-water treatment of the 
continued fevers is attended with a remarkably small percentage of 
deaths. 

If instead of studying the subject in these marred statistics the 
evidence furnished by single observers in favor of antipyresis by cold be 

5 













66 


CALORIC. 


examined, the results are even more positive * It is stated by Winter- 
nitz ( Verhandl. des Congr.f. Innere Med., 1886, 5) that in the French and 
Austrian armies the antipyretic treatment of cold has not been employed, 
■while in the German army it is practised more or less zealously. The 
mortality in the French army averages 36.9 per cent., in the Austrian 
27.4, and in the German only 9.6. That this decreased mortality is 
due to the antipyresis seems to be established by the fact affirmed by 
Brandt, that in the Second German Army Corps, in which the treatment 
is carried out more thoroughly and systematically than in the other 
corps, the mortality is less than four per cent., and that, too, in the face 
of the fact that in the same hospitals, from 1849 to 1856, the mortality 
was twenty-six per cent. Jiirgensen states that from the year 1850 to 
1861 there had been treated in the hospital at Kiel, according to the 
expectant method, three hundred and thirty typhoid fever patients, 
with a mortality of 15.4 per cent.; while from 1863 to 1866, during 
which period the antipyretic method was employed, in one hundred and 
sixty cases the mortality was 3.1 per cent. Professor Liebermeister has 
employed the cold-water treatment on a larger scale than has any other 
individual. At the hospital at Basel, up to the year 1865, one thousand 
seven hundred and eighteen cases of typhoid fever were treated upon 
the expectant plan, with a mortality of 27.3 per cent. In 1865, Dr. 
Liebermeister introduced the use of cold bathing in a timid, inefficient 
manner, and reduced the mortality, in nine hundred and eighty-two 
patients treated, to 16.2 per cent. In 1866 he began the vigorous 
regular employment of the method, and reduced the death-rate, in one 
thousand one hundred and twenty-one patients treated, to 8.2 per cent. 
Professor Liebermeister himself criticises very closely, in Ziemssen’s 
“Encyclopedia of Medicine,” these statistics, and raises the mortality, 
by excluding trifling cases, to from ten to eleven per cent.; but, after the 
antipyretic treatment has been even unjustly dealt with, the statistics 
still show that the mortality under the cold-water treatment is not half 
what it formerly was. Further, a certain proportion of cases are always 
admitted to the hospital moribund, too late for any human agency to be 
of avail: these cases, of course, maintain the same proportion under any 
treatment; they really constitute a large part of the deaths seen in the 
cold-water treatment, so that if they were eliminated from both sides 
the death-rate “ under the antipyretic plan would be but a small fraction 
of what it would be under the other.” 

In hospital practice the patients are very rarely received upon the 
first day of the attack, and very frequently do not enter the wards 


* M. Franz Gl€nard affirms {Glasgow Med. Journ., 1874) that there have been from six 
thousand to eight thousand cases of typhoid fever treated by the use of cold in Austria, Prus¬ 
sia, and Kussia, with an average mortality of from 4.5 to 7.6 per cent.,—the previous mortality 
under the old expectant method having varied from eighteen to twenty-five per cent. If 
these figures be correct, they are decisive. Where M. Glenard gets them from, however, I do 
not know. 



COLD IN PYREXIA. 


67 


until the third week, so that the statistics, as already intimated, favor¬ 
able as they are to the new treatment, express only a portion of the 
truth. If the good effected be so great when the remedy is often not 
applied until the second or third week, much more is to be expected 
when it is employed faithfully from the moment the temperature be¬ 
comes elevated. 

All those physicians who advocate the use of cold baths in typhoid 
and typhus fevers appear to be agreed that, although the mortality is 
very much reduced, the duration of the disease is shortened only in so 
far as complications are avoided. As, however, the patient is left by 
the disease much stronger than he is when the expectant method of 
treatment is pursued, convalescence is much more rapid than under the 
old plans. By the antipyretic treatment the intense prostration, deli¬ 
rium, stupor, carphologia, involuntary passages, and other manifesta¬ 
tions of the typhoid state are greatly lessened. The relief afforded is 
so evident to both patient and attendants that they usually, after one 
trial, acquiesce in the regular employment of the cold baths, although 
to the one the sensations are at first very disagreeable, and for the 
other the labor and attention required are very much increased. The 
antipyretic use of cold in typhoid fever has not, however, been free 
from determined opposition (see discussions in Le Progres Med., 1877; 
also Bull. The rap ., xci.), and the assertions in its favor are some of them 
evident exaggerations. I am, however, thoroughly convinced by my 
own experience, as well as by the great mass of recorded evidence, that 
the treatment of typhus and typhoid fever by cold is of the utmost 
value, and I believe that the cold bath is much safer and more efficient 
than are antipyretic drugs. In America the method has met with com¬ 
paratively little favor, chiefly because of the labor it involves and of 
the prejudice of the laity. I have no doubt that very many persons 
have died in the United States of typhoid fever whose lives would 
have been saved if the American medical profession had risen above 
the opposition of the laity and above its own prejudice. 

A very practical question, but one which we are as yet scarcely in a 
position to answer fully, is, What are the contra-indications to the use 
of cold in fever ? According to our old ways of thinking, bronchitis 
and pneumonia would especially seem to be in the way. The serious 
lung-affections of low fevers are, however, largely dependent upon the 
general adynamia, and this adynamia is, in turn, largely the result of the 
excessive temperature. Accordingly, the German investigators have 
not found the baths to do harm in the pneumonias of exanthemata. 
Liebermeister, who has had more experience than any other observer, 
says that “pneumonia, hypostatic congestion, and the like, offer no 
reason for suspending the baths: the hypostatic troubles sometimes 
disappear under their use.” I have carried one or two cases, in which 
the lung-symptoms were veiy severe throughout, to a successful issue, 
employing cold freely, and was unable to perceive any evil effect upon 


68 


CALORIC. 


the lungs. Prof. Eaynaud, as the result of his experience, affirms em¬ 
phatically that neither pulmonic nor intestinal complications should 
interfere with the use of the cold bath (Bull. Therap., xci.). On the 
other hand, Proust reports ( Ibid ., xcii.) two cases in which fatal 
pneumonia of the ordinary type, not the hypostatic pneumonia of 
advanced fever, was apparently produced by cold baths. Dr. Alix 
also reports two deaths from pneumonia in three cases in which he 
tried the baths. My own feeling is that severe bronchitic or pneu¬ 
monic symptoms occurring in the beginning of typhoid fever should 
make us very cautious in using the antipyretic method, but that when 
they occur late in the fever, and are due rather to hypostasis than to 
inflammation, they are not contra-indications to the use of the bath. 
Professor Liebermeister affirms that perforation of or hemorrhage from 
the bowels is a contra-indication to the use of cold in fever, because 
cold has a tendency to produce determination of blood to the internal 
organs. The experience of Wunderlich ( Schmidt's Jahrbucher, Bd. clvi. 
p. 101) is, however, very much opposed to this idea of Liebermeister’s. 
He treated sixteen cases of severe intestinal hemorrhage with cold baths, 
with but two deaths,—neither of which resulted directly from the 
hemorrhage, one being from intestinal perforation and one from severe 
pneumonia. This mortality is certainly a very small one, for when 
cold water was not employed, out of thirty-two cases Griesinger had 
ten deaths; out of twenty-one Jenner lost seven; out of fourteen Gietl 
lost six; and Jaccoud had six deaths in six cases ( Pathologie Interne , t. 
ii. p. 758). Bauer, however ( Schmidt's Jahrbucher , Bd. clvi. p. 101), is 
in agreement with Liebermeister in believing that the baths should 
be discontinued during intestinal hemorrhage. Yet their views seem to 
be based upon preconceived theory rather than upon actual trial. Thus, 
Liebermeister says, “ I have thus far ordered the baths entirely discon¬ 
tinued as soon as even slight hemorrhage from the bowels occurred.” 
The proportion of cases in which intestinal hemorrhage occurs does 
not seem to be increased by the cold-water treatment; at least Gols- 
dammer ( Berlin. Klin. Wocli., 1877, p. 98) affirms that under the older 
methods thirteen thousand five hundred and sixty-three cases gave five 
hundred and thirty of intestinal hemorrhage, while five thousand six 
hundred and thirty-six cases of cold-water treatment yielded two hun¬ 
dred and forty of intestinal hemorrhage, the percentage being in the 
two cases respectively 3.9 and 4.2. Menstruation is not looked upon 
as a contra-indication. Brandt appears to consider a contra-indication 
to the use of the cold bath in typhus fever a myth, and the drift of 
testimony is such that no local internal disease ought in the present 
state of our knowledge to be considered as absolutely contra-indicating 
the use of cold baths when the temperature is high in typhus or typhoid 
fevers. 

It is otherwise when there is a general tendency to collapse,—when 
the heart is so weak that local stases of blood occur in almost all the 


COLD IN PYREXIA. 


69 


internal organs. Under these circumstances the circulation has not 
sufficient power thoroughly to equalize animal heat, so that it is said 
to be entirely possible to cool the exterior of the body several degrees 
without materially affecting the temperature of the interior. One of 
the severe accidents which it is affirmed has very rarely followed the 
use of the cold bath in pyrexia is a sudden collapse; and clinical expe¬ 
rience seems to indicate that when collapse is already existent the cold 
bath should not be administered. 

In no disease attended with a long-continued pyrexia has the cold- 
water treatment been employed upon so grand a scale as in typhus and 
typhoid fevers; but the results there obtained are sufficient to indicate 
its usefulness in allied diseases. Of all the exanthemata, none is more 
constantly attended with excessive temperature than is scarlet fever. 
In this disorder the testimony to the value of cold is very strong. 
Going back to Currie, who really first systematized the abstraction of 
heat in fever, we find that he habitually practised in the most heroic 
manner cold affusions in the treatment of scarlet fever, and claimed the 
greatest success for the measure. Since his day the remedy has been 
employed with asserted good results by various observers, among whom 
may be mentioned Gerard, Bruere, Gianniui, Armstrong, Laycock, Ril- 
liet and Barthey, Trousseau, and Hiram Corson of Pennsylvania. The 
evidence is, unfortunately, too much generalized to allow of its being 
put in a statistical form, but for an extended resume of it the reader 
is referred to the excellent article in Meigs and Pepper’s work on the 
diseases of children. In almost all of these cases the cold was applied 
in the form of affusions, a method which is certainly far more terrifying 
to the child, and probably less efficient, than the cold bath. Recently, 
Hr. G. Mayer ( Jahrbuch fur Kinderkrankheiten, vii. 4) has been placing 
the child in a bath of from 93° F. to 73° F. (according to the intensity of 
the fever) for ten minutes, whenever the temperature rises above 102° F. 
He affirms that the effect was most beneficial, and that the reduction of 
temperature usually lasted for several hours. In diphtheria , cold bathing 
has been used to some extent, with seemingly good results. In both 
this affection and in anginose scarlatina it is of the utmost importance 
to combine the cold bathing with the local application of the ice-bag or 
ice-poultice to the'throat. During the summer months serous diarrhoea 
(cholera infantum ), in some of its forms, annually destroys large num¬ 
bers of children in this country. In most of these cases the bodily 
temperature is, first or last, much elevated, and the diarrhoea is pro¬ 
duced and maintained by the heat, as originally pointed out by Dr. 
Comegys ( Philada. Med. Times , v. 665; Amer. Journ. Med. Sci., Oct. 
1876). All the ordinary methods of drug-administration frequently fail, 
or, at most, succeed only in keeping the child alive until the heat of the 
weather subsides. Under these circumstances antipyretic treatment 
acts in a magical manner. I have always found simple bathing in 
water of about 75°, at intervals of from three to six hours, sufficient, 


70 


CALORIC. 


but in some cases the plan recommended by Dr. Comegys may be re¬ 
quired,—namely, by cold affusions while the child is sitting in a cold 
bath. The effect is usually immediate, quiet and sleep at once replacing 
the wakeful restlessness so distressing to mother and child. There may 
be a few instances of sudden collapse with low temperature from ex¬ 
haustion by the serous discharges, but usually cases in which the disease 
is said to “go to the head’’ are those in which the temperature rises 
so high as to produce brain-symptoms: under these circumstances the 
vigorous use of external cold is imperatively demanded. 

It is in the highest degree probable that systematic cold bathing will 
be found serviceable in all blood-poisonings with high temperature, such 
as smallpox, erysipelas, pygemia, etc.; but as yet we have no clinical 
evidence of moment upon the matter. The high temperature that 
prevails in sthenic pneumonia and certain other inflammatory diseases 
would appear to indicate the abstraction of heat; but how far the local 
disease will be advantageously or disadvantageous^ affected in these 
cases is as yet an open question. Dr. G. Mayer ( Schmidt's Jalirb ., Bd. 
cxlix. p. 347) is stated to have found that defervescence is materially 
hastened, both in men and in children, by cold bathing. Dr. Kissler 
(Virchows Archiv, Bd. xciv. p. 490) had in one epidemic a mortality of 
17.4 per cent, in twenty-three cases treated with the cold bath, and of 
57.1 per cent, in twenty-one cases treated otherwise; and Liebermeister 
states that whilst in six hundred and ninety-two cases of pneumonia 
treated in the hospital of Basel in various ways the mortality was 25.3 
per cent., in two hundred and thirty cases treated in the same hospital 
by the thorough antipyretic method the mortality was only 16.5 per 
cent. Liebermeister has also employed the method in catarrhal pneu¬ 
monia, puerperal fever, cerebro-spinal meningitis, acute rheumatism, ery¬ 
sipelas, smallpox, and quinsy, and affirms that he knows of no case with 
acute febrile symptoms in which, if the rise of the temperature were 
considerable, or lasted too long, he should consider heat-abstraction un¬ 
suitable treatment. In dysentery, Dr. B. Wenzell (The Doctor , 1874) 
strongly advises the use of large enemata of ice-water, which by their 
local action relieve very greatly the pain and tenesmus and at the same 
time have a decided effect upon the pyrexia. 

In carrying out the antipyretic treatment of fever certain general 
considerations should never be forgotten. It appears to be impossible 
to give a fever patient cold unless the temperature of the body be 
reduced to near the norm. In many instances the fall of temperature 
continues after the patient has been taken out of the bath: hence the 
bath should not be too prolonged. I have been accustomed to believe 
that the good achieved by the bath was simply the result of with¬ 
drawal of the heating, and have therefore employed it only when the 
excessive bodily temperature threatened injury, and have considered 
the danger-j)oint to be a mouth-temperature of 103° F. Some of the 
Germans, however, employ the bath whenever the temperature reaches 


COLD IN PYREXIA. 


71 


102° F. in the axilla. As it is possible to cool the axilla without cooling 
the interior of the body, all temperatures should be taken in the mouth 
or the rectum. Again, no bath or other application does good unless it 
removes the heat, but the cold should never be applied more severely 
than necessary. I have used cold spongings, cold packings, and the 
various baths, and have found that when a portable bath-tub can be 
brought to the bedside of the patient and readily filled and emptied, its 
use is accompanied with less fatigue and disturbance than any other 
efficient means of employing cold. The patient, wrapped in a sheet, is 
to be lifted by two attendants into the bath, and then made comfortable 
with pillows, etc. Unless the pyrexia is very severe, the bath should 
be at a temperature of 90° F. and cooled down pro re nata. When no 
portable bath-tub is at hand, sufficient antipyresis may be had by lift¬ 
ing the patient, wrapped in a sheet, upon a cot covered with a rubber 
blanket, and sousing rather than sponging him with cold water from a 
large carriage-sponge. If the sacking-bottom or the canvas of the cot 
be so loose as to sag down several inches, and the rubber blanket be 
turned up at the bottom and top over a wide board nailed across the 
top and bottom, the patient during the sponging lies in a big pool of 
water, and all the effect of the cold bath is obtained by removing with 
a carriage-sponge this water as fast as heated, and sousing fresh cold 
water (ice-water if necessary) freely over the upper part of the patient. 
Under no circumstances should the patient be allowed to help himself 
at all during the various movements. When the extremities seem 
especially affected by the bath, they should be rubbed so as to maintain 
their circulation. I have frequently applied hot-water bottles to the 
feet while the body was being bathed, with good effect. 


CHAPTER IV. 

ELECTRICITY. 


General Considerations. —Electricity is a force which is developed 
in various ways, but which is essentially the same entity under all cir¬ 
cumstances. When it is obtained by rubbing two 
surfaces together, it is known as frictional electricity; 
when it is obtained by the union of two dissimilar 
metals, it is called galvanism. Frictional electricity 
is almost never used in medical practice, and I shall 
say nothing more about it in this book. 

There are a large number of different patterns or 
arrangements of the elements which generate gal¬ 
vanism, but the ideal or typical cell may be said to 
be formed of two dissimilar metals immersed in some 
corrosive liquid and connected with each other by a 
piece of wire externally. Under these circumstances 
the current starts from the metal most easily cor¬ 
roded, passing through the liquid to that less easily acted upon, and 
from this over the external wire to the starting-point. The external 
end of the least-easily corroded plate is therefore always giving off 
electricity, and is known as the -f- or positive pole, while the corre¬ 
sponding end of the other plate is constantly receiving electricity, and 
is spoken of as the — or negative pole. When wires are attached to 
these plates they become, as it were, prolongations of the plates, and 
their ends constitute the poles. Thus, in the diagram, C = copper, 
Z = zinc, P and N = poles, and the arrows show the direction of the 
current. The positive pole is called the anode (dvd, upwards, and 
a way); the negative, the cathode (xa-d, downwards, and d<5o?). 

As the electric current does not primarily exist, it is evident that in 
the typical or ideal galvanic cell there must be something which sets 
it in motion. This force is the so-called electro-motor force, and has 
been determined by physicists to be a definite quantity for the same 
combination of metals at the one temperature. This force is gener¬ 
ated at the point of contact of the metals, in obedience to the law 
discovered by Volta, that when two metals are in contact with each 
other a disturbance of the electrical conditions of those metals occurs. 
The amount and energy of this disturbance vary according to the 
nature of the metals, and experiments have shown that all metals have 
72 






ELECTRICITY. 


73 


definite electro-motor powers or properties, and that they can readily 
be arranged in a regular series. A study of this series is not necessary 
to an understanding of electro-therapeutics, and the reader desirous of 
knowledge upon this especial point is referred to works on physics. 
It must be borne in mind that the electro-motor force is constant, so 
that in any given combination of metals in a galvanic cell the electro¬ 
motor force is always the same, whether the plates of the metal be large 
or small, whether the solution be an acid, a saline, or pure water. The 
strength of the current is not, however, decided entirely by the electro¬ 
motor force of the cell. Every known substance refuses more or less 
imperiously to allow the passage of electricity. The best conductors 
oppose a really very great resistance. Now, it is evident that this 
resistance is opposed to the electro-motor force, and that if it be greater 
than the latter it will altogether prevent the passage of any current. 
The strength of the current, then, depends upon the relation between 
the resistance and the electro-motor force ; and we have the celebrated 
law of Ohm, which may be expressed by the formula c ( current-strength ) 

e (electro-motor force ) . 

=- 7 --r-This law experiment has shown to be lmpera- 

r (resistance) ^ ^ 

tive, no increase or diminution of the size of the plates, no change in 

the character of the solution, affecting it. 

The resistance to the current in a galvanic combination is a double 
one: inside of the cell the fluid between the plates opposes the passage 
of the electricity, and outside of the cell the conductor which completes 
the circuit also offers a resistance. The reason a battery almost ceases 
to yield a current when water is substituted for the acid usually em¬ 
ployed is not a purely chemical one, but simply because water is an 
almost complete non-conductor, and offers triumphant resistance to the 
current, while the acid conducts and readily allows the current to pass. 
The entire resistance (r) is then made up of two factors: the internal 
resistance ( ir ), and the external resistance (er). The formula of Ohm 

£ 

may therefore be read c =- 

ir -)- er 

As already stated, when the plates of a cell are increased in size the 
electro-motor force is not increased, but as the surfaces of the plates are 
increased the diameter of the conductor— i.e., the mass of fluids between 
the plates—is increased; and consequently, as the resistance in a con¬ 
ductor is inversely as the size of its cross-section, the strength of the 
current is increased. To make this a little clearer, suppose ir in a 


certain cell equal 10 , then c = 


10 -(- er 


if now the plates of the cell 


be doubled in size, c =--=-. A similar result— i.e.. less- 

+ er 5 -f er 

ening of the internal resistance—can be achieved by shortening the 
distance between the plates of the cell,— i.e., the length of the con- 







74 


ELECTRICITY. 


ductor,—or by in any way making the intervening liquid a better 
conductor. 

The change in strength of a current by the increase of the size of 
the plates of the cells can readily be expressed by the formula of Ohm. 
If the letters signify as before, and the internal resistance be diminished 

y times by increasing the size of the plate y times, instead of c = - — 

c _ e If, instead of a single cell, a number of cells are 

arranged in such a way that the copper of one is con- 


ir 


-f- er 


y nected with the zinc of the next, the electro-motor 

force of the combination is equal to the sum of the electro-motor forces 
of the cell: thus, if e = the electro-motor force of the single cell, and 
y = the number of cells, the electro-motor force of the battery will 
be ye. It is plain that the internal resistance of the battery is also 

increased y times, so that the formula of Ohm will stand c = —^—. 

yir + er 

Of course, the strength of a current is greatly affected by the ex¬ 
ternal resistance. In very many instances the external resistance is 
enormous. Suppose, then, this external resistance in a given case be 
1000 times the internal resistance, the formula of Ohm will read, 

c = -. It is evident that under these circumstances ir, the 

ir + 1000 ir 

internal resistance, becomes very insignificant, and that very little is 
gained by increasing the size of the plates,— i.e., by diminishing the 
internal resistance; for if the plates were increased fivefold, the in¬ 
crease of the strength of the current would only be the difference 

C 6 

between - and -——-, a difference which is very 

ir , 1AA a • ir + 1000 lr 
—\- 1000 ir 
5 

slight. On the other hand, when the external resistance is very great, 
everything is gained by increasing the number of cells,— i.e., increasing 

5 e 

the electro-motor power; for-gives a very different re- 

5 ir + 1000 ir J 

£ 

suit from -- When, therefore, the external resistance is many 

ir -f- 1000 ir ' * 

times greater than the internal, ■practically nothing is gained by increasing 

the size of the plates , everything by increasing the number of the elements. 

The converse of the above reasoning also holds. If the external 

resistance be very slight, the internal rises in importance. Thus, sup¬ 


pose er = 


ir 


1000 


Then the formula would be c = 


ir -f- 


ir 


In this 


1000 


case a great deal is gained by increasing the size of the plates, for 


ir , ir 

5 + 1000 


gives a very different result from 


ir -f- 


ir 


In such a case, 


1000 

















ELECTRICITY. 


75 


by quintupling the size of the plates the strength of the current is 
practically increased fivefold. On the other hand, it is plain that when 
the external resistance is slight the gain by increasing the number of 
cells is a slight one, for the internal resistance is increased as many 
times as the electro-motor force. Thus, if five cells are used, the 

^ p 

which will, of course, give practically 


formula will be c 


5 ir + 


ir 


1000 


the same result as 


e 


ir + 


ir 

1000 


The law, then, may be stated to be that when the external resistance 
is very slight, increasing the number of the elements has no practical effect 
upon the strength of the current, while an increase of the size of the elements 
has the greatest effect. 

When there is no very great disproportion between the internal and the 
external resistance, it is evident that the strength of the current may be in¬ 
creased by increasing either the size or the number of the elements. Thus, 

if er = ir, c = —--= —-—; and increasing the size of the plates 

ir + er ir + ir 


fourfold will give the formula c — 



or increasing the num¬ 


ber of the elements to four will yield the formula c 
haps the result will be clearer if figures be used. 


4 e 


Per- 

4 ir + ir 
Suppose e = 100, 


ir = 10, and er = 10. Then the first formula will be c — 


the second, c = 


100 


— + 10 
4 ^ 


= 8 ; the third, c 


400 


40 + 10 


100 . 

-= 5 ; 

10 + 10 

= 8. When, 


therefore, the external and the internal resistance are equally balanced, the 
strength of the current is equally increased by increasing either the number 
or the size of the plates. 

The application of the foregoing principles to electro-therapeutics is 
a very simple one. In the ordinary applications of electricity to the 
body, the resistance of the tissues is very many times greater than the 
internal resistance of any battery, and consequently the latter may be 
totally disregarded. Hence for ordinary purposes the formula stands 


c — —, and power can be gained only by increasing e, —that is, by 
re 

augmenting the number of cells. 

When, however, it is desired to act upon the blood in an aneu- 
rismal sac, the needles are brought close to each other; and, moreover, 
the blood is a comparatively good conductor of electricity. Hence in 
such cases the external resistance is so much reduced that the internal 













76 


ELECTRICITY. 


becomes of such importance that it should not be overlooked. It fol¬ 
lows, therefore, that when an aneurism is to be acted upon the plates 
should be increased in size, while at the same time a number of cells 
should be used. 

In the so-called “ galvano-cautery” the current is not passed through 
the body at all, but through a wire, which is thus kept at a white heat. 
In this case the external resistance is vastly less than when human 
tissues form a part of the circuit. Hence it becomes a matter of im- 
portance to reduce to as great a degree as possible the internal resist¬ 
ance, and the elements or plates should be very large and should be 
placed very close to one another in the cells. The external resistance 
is not, however, so slight that it can be entirely overlooked, and hence 
a number of cells are combined with one another, so as to give sufficient 
electro-motor force. 

In writing or speaking about the use of electricity in medicine, it is 
a matter of great importance to avoid the use of the old terms quantity 
and intensity , which, to use the language of one of the most eminent of 
living writers on galvanism, “ are remnants of an erroneous theory.” 
The amount of mystification which has been produced by talk con¬ 
cerning the therapeutic effects of currents of large quantity with low 
intensity as contrasted with those of currents of high intensity and 
low quantity is equalled only by the amount of nonsense which has 
been written. Currents of galvanism have really only one attribute, 
— i.e., current-strength,—and that is in strict accordance with the law 
of Ohm. 

If o = — it is evident that, in order to have a unit by which there can 
r 

be a measurement of an electric current, it is necessary to have a unit 
of resistance and a unit of electro-motor force. The unit which has been 
finally settled upon by electricians as the measure of electro-motor force 
is known as a volt. It is equivalent to 10 8 (10 raised to its eighth power) 
absolute French units of force* The unit of resistance is termed an ohm , 
and equals 10® absolute French units. Substituting these units for their 

representative letters in the formula c — we get c = - vo ^ . In this 

r ' 1 ohm 

way the unit of current-strength is obtained, and is known as an ampere. 
This unit is, however, entirely too large for practical purposes. It is 
therefore generally substituted by the so-called milliampere, which is 

the one-thousandth part of an ampere, or — ^ vo ^‘ —. The term gal- 
vanometer has long been used in electricity as the name of an instrument 


* All forces are convertible into one another, and hence it is possible to refer the unit 
which is employed in measuring electricity, heat, or other force to what is known as the 
absolute unit of force. The absolute unit of force is always mechanical, and has in the past 
varied in different countries. At present, however, scientists almost universally adopt the 
French unit, which is a representation of the amount of force required to raise one gramme 
through one centimetre of distance in one second. 





ELECTRICITY. 


77 


which shows the existence of an electro-current. An absolute galva¬ 
nometer is one which reveals not only the current, but also the amount 
of electricity that is passing. As good absolute galvanometers are now 
manufactured which measure the current in milliamperes, it would seem 
at first to be a very easy matter, in testing the excitability of nerves 
or in reporting cases treated by electricity, to state exactly how many 
milliamperes passed through the nerve or through the system; in other 
words, it would seem easy to have a dosage of electricity comparable to 
that of medicines. Unfortunately, the affair is not so simple,—chiefly on 
account of the diffusion of the electrical current which naturally takes 
place during its passage through the human body. If, for instance, an 
electrode of a square inch of surface be used, the effect upon the organism 
must be different from that which would be obtained by employing an 
electrode of twenty square inches. In the one case a concentrated cur¬ 
rent would pass at least for some little distance into the body, in the 
other a large number of proportionally feebler currents would enter 
from the beginning. More than this, when it is intended to galvanize 
a fixed spot, as a ganglion or nerve-trunk, it is rarely possible to note 
exactly what portion of the current which enters the body reaches the 
desired spot, and how much of it is diffused through other tissues. (See 
paragraph on conduction.) In order, therefore, to compare results ob¬ 
tained by different electricians, or by the same electrician upon the same 
case in successive days, or in different cases, it is essential to know ex¬ 
actly the size of the electrodes and the positions at which they were 
placed upon the body. To facilitate measurements, Mr. C. W. Muller 
has proposed that in therapeutic electricity a fraction be used to ex¬ 
press the concentration of the current which is employed, the numer¬ 
ator of the fraction to consist of the number of milliamperes, the denomi¬ 
nator of the number of square centimetres in the electrode. Thus, the 
fraction would mean that a current of one milliampere strength had 
been employed with an electrode of thirty centimetres of surface, while 
the fraction T 4 g would mean that the current of four milliamperes had 
been employed through an electrode of sixteen square centimetres of 
surface. These fractions do not express in any way the relative posi¬ 
tions of the electrode, and the alteration of half an inch in the position 
of an electrode on the surface of the body may double or halve the 
amount of a current which reaches the desired spot. Practical dosage 
of electricity in therapeutics is probably a chimera, and certainly has 
not yet been satisfactorily achieved. It is possible that in certain deli¬ 
cate cases, with very careful investigators, the measurement may be 
employed with advantage for the study of physiological results. But 
one who is familiar with the average training in physical science of 
physicians who use electricity must, I think, recognize that the publica¬ 
tions of electrical measurements amount to little more than a show of 
scientific accuracy. 

For ordinary use in diagnosis and treatment of disease galvanome- 


78 


ELECTRICITY. 


ters are not required, the experienced medical electrician being suffi¬ 
ciently guided by the sensations of the patient and the muscular effects 
achieved. 

A dense fog has been thrown around the subject of electro-thera¬ 
peutics by the idea that there are various essentially different forms of 
galvanism. The current which flows from a cell or a combination of 
cells is spoken of as a continuous current , or sometimes as a primary cur¬ 
rent; besides this, modern therapeutists use another series of currents, 
which are known as the induced currents. 

The term primary current is often applied to one of these induced 
currents. If we employ the name continuous current for that current . 
derived from the galvanic cell, we must continually be speaking of the 
interrupted continuous current, which certainly is inelegant. I shall, 
therefore, employ the name chemical current or galvanic current to desig¬ 
nate that form of galvanism which is generated in the galvanic cell. 

If a coil of insulated wire have a bar of soft iron placed in its centre 
and be surrounded by an external coil of wire, when a chemical current 
is passed through the first coil, owing to physical laws which it is not 
necessary here to consider, every time the galvanic circuit is completed 
or interrupted a brief current of electricity is induced in the inner or 
first coil, and also a similar current in the outer or second coil. The 
only physical facts which it is necessary for us to know are that these 
induced currents are very brief and of great strength, also that they 
are to-and-fro currents,—that is, run in opposite directions in each indi¬ 
vidual coil. Thus, in the inner or first coil, when the galvanic circuit is 
closed, the induced current in the inner coil runs parallel to the gener¬ 
ator chemical current; but when this latter current is broken, the induced 
current runs in a contrary direction. In the outer coil, the induced 
current, which is instantaneously developed when the galvanic current 
is sent through the inner coil, pursues a direction opposite to that of the 
chemical current; but when the latter is broken, the return induced 
current in the outer coil runs parallel to the generator current. 

As these induced currents run backwards and forwards, to and fro, 
in this way, it would appear that there could not be any negative or 
positive pole to the battery which generates them, for if one end or pole 
of the wire constituting the coil be negative in regard to the first in¬ 
duced current, it must be positive in regard to the second or return 
current. This is assuredly true so far as concerns the outer or second 
coil, but is not true for the inner or first coil, as is readily understood by 
means of the diagram of an induction battery given on the opposite page. 

It is plain that when the current is passing, the hammer h being 
in the position represented in the diagram, m will become magnetic 
and attract h. This at once breaks the current, and an induced current 
runs through the first coil and is received by the patient grasping the 
handles P P. The instant the current is interrupted, m loses its mag¬ 
netism and the spring-hammer flies back. Now the circuit is closed, 


ELECTRICITY. 


79 


and for the second time an induced current runs through the first 
coil c. It is evident, however, that this induced current of closure 
will not pass through the body of the person grasping the handles PP, 
but will pass along h through the cell to the other end of the coil, as a 
shorter route and one of vastly less resistance. It is plain that from 
the inner or first coil the induced current of broken circuit alone passes 
through the body of the patient. 


Fiq. 2. 



G, galvanic element, with the + and — metals in it; c, coil in which the primary induced 
current, or current of the first coil, is generated; h, spring-hammer or vibrator; m, a piece 
of soft iron becoming a magnet when the current is passing; 2c, outer coil in which the 
secondary induced current, or current of the second coil, is generated; P, handles of inner 
coil; P', handles of outer coil. 


In regard to the outer coil, it is evident that when the circuit is 
closed the momentary induced current must run through the body of 
him who grasps the handles P' and P / , and that the return current 
which passes when the circuit is broken must take the same route. 

It follows from the above considerations that the current of the first 
coil runs through the patient only in one direction , and electricians may 
correctly mark poles -)- and —, but that the current of the second coil 
runs in both directions , so that any designation of its handles as posi¬ 
tive and negative is incorrect. The only justification for the marking 
of the secondary or outer current poles, as is often done, is found in 
the fact that the induced current of the broken circuit is stronger than 
that of the closed circuit. Hence it is that with very strong currents 
the two poles can sometimes be distinguished when grasped in the 
hand. The difference is, however, a slight one, and for all practical 






80 


ELECTRICITY. 


purposes the induced current of the outer coil is a to-and-fro one, 
without any negative or positive poles. 

If a strong continuous galvanic current be passed through a person, 
a shock is felt at the moment of making and breaking the circuit, but 
while the current is passing no sensation is perceived except at the 
points of entrance and exit. Or if the current be passed through the 
nerve of a muscle, that muscle violently contracts at the moment the 
circuit is made or broken, but while the current is flowing is quiescent. 
If a rapidly-interrupted faradic current be passed through a nerve, the 
muscle supplied by that nerve is thrown into a continuous spasm. The 
reason of this is obvious. The so-called faradic or induced current is, 
as has already been stated, a succession of instantaneous broken cur¬ 
rents for the first coil, and as brief to-and-fro currents for the outer 
coil; so that the circuit is continually being closed and broken, and the 
muscle is continually excited to action. There is, therefore, a different 
result achieved in the application of the continuous and induced cur¬ 
rents, not because there is any real difference in their nature, but 
because the mode of application is diverse. 

Most medical electricians teach that the true galvanic current is 
very different from the faradic current, and many, like Duchenne, 
persist in asserting that the currents of the first coil are essentially 
different from those of the second. Galvanism is, however, galvanism; 
and its nature and attributes are probably always the same; the faradic 
currents are lacking in the chemical power of the continuous current 
because they pass so quickly that they have not time to exert a chem¬ 
ical influence. Gunpowder can be passed so quickly through the hot¬ 
test flame as not to be ignited. The secondary induced current differs 
somewhat in its action from the primary simply because the latter is 
not a to-and-fro current, and we cannot readily convert an induced 
into a galvanic or chemical current, because we cannot readily tie 
together, as it were, the ends of the brief currents into one. I have 
no doubt that if we could get the interruptions at the rate of many 
thousand times a minute, we should find that the primary induced cur¬ 
rent would act as a continuous current.* 

We can readily, by mechanical means and contrivances, interrupt 
the continuous current, or even rapidly reverse the poles so as to give a 
to-and-fro current like that of the outer coil. When this is done, it is 
impossible to distinguish between the action of the galvanic and that 
of the faradic current in producing muscular contractions. It is true 


* It has been found that when a faradic machine, or its equivalent, the so-called magneto- 
galvanic machine, is so constructed that the interruptions are excessively rapid and the to- 
and-fro currents separate from one another, the infinitely rapid succession of instantaneous 
induced currents in one direction has all the chemical effects of a steady current; in other 
words, the interruptions are so brief that they are without influence. I am not aware of any 
trials with these machines upon living tissues, but do not doubt that their currents will be 
found to produce the same results as chemical currents. 



ELECTRICITY. 


81 


that in certain diseased states of the muscle it has been asserted, and 
with apparent reason, that the action of the induced current is essen¬ 
tially different from that of the true galvanic current. But I believe 
further investigation will show that the seeming differences are really 
due to the difference in the lengths of time during which the currents 
are passing, and not to any inherent peculiarities of the various currents 
themselves. 

It is of the utmost importance to determine by what route or routes 
galvanic currents pass through the body when the poles are applied to 
it, and, since the body as a galvanic conductor is governed by ordinary 
physical laws, some knowledge of these laws is a necessity to the electro¬ 
therapeutist. 

If a current be passing along a homogeneous conductor, such as a 
wire of iron, of copper, or of other metal, and that conductor splits up 
into a number of branches, the current also divides, as is illustrated in 
the diagram (Fig. 3). If these branches, being of equal size and length, 
offer an equal resistance, the cur¬ 
rent divides equally; but if the 
size or length, and consequently 
the resistance, of the branches be 
unequal, the division of the cur¬ 
rent is unequal; the law being that 
the strength of the current in each 
branch of the conductor is inversely 
proportional to the resistance of 
that branch. This law is as applicable to conductors composed of 
many substances as to those composed of a single substance; but then 
the resistance in a branch depends upon the specific resistance of the 
substance of which it is composed, as well as upon its size and length. 

In applying these laws to the passage of galvanism through the 
body, it must be borne in mind that the dry skin offers an enormous 
resistance to the passage of the current, so that practically none of the 
latter will pass along it. On the other hand, when the skin is thor¬ 
oughly wet with salt water it allows the current to pass through it 
readily. 

Let us suppose, then, that in the diagram (Fig. 4) -\-p and —p = 
wetted poles; ss = skin, with the tissues below it. It is evident that, 
if the tissues were a uniform mass, the current, passing through the 
skin as a solid bolt, would break up into an infinite number of curved 
currents, which would meet and pass through the skin again as a solid 
mass at — p. It is equally plain that, of these sub-currents, those 
whose course was nearest the straight line from -J -p to —p would be 
the shortest, and would, therefore, meeting with the least resistance, 
be the strongest, while as the curve and consequently the length and 
the resistance increased, the strength of the current would diminish 
until it became practically null. In this imaginary case the tissue 

6 




82 


ELECTRICITY. 


beneath the skin has been supposed to be homogeneous: in actual life 
the tissue never is homogeneous, and the resistance of the different 
constituents varies somewhat. Consequently, the strength of the sub¬ 
divisions of the current is modified,—those branch streams being in¬ 
creased which run along or through tissues that conduct readily, and 
vice versa. 

Fig. 4. 



By remembering these facts, we are enabled to apply electricity as 
closely as may be to any desired portions of the body. Thus, if it be 
intended to affect as exclusively as possible a certain spot or minute 
portion of a nerve, a well-wetted small electrode is placed directly over 
this portion, and, especially if the nerve be somewhat deeply situated, 
pressed down firmly, so as to condense the tissues as far as possible 
into a homogeneous mass, while a large wet electrode is placed at a 
small distance from it in a situation which the anatomy of the part 
will readily suggest. The diagram (Fig. 5) will perhaps illustrate this 
point more clearly than would many words. 


Fig. 5. 



It is evident that the spot immediately under the small electrode 
will receive the full strength of the current, which is directly afterwards 
so broken up as to affect very slightly any other part. 

Again, suppose it is desired to pass a current through some length 
of a nerve; it is evident, in the first place, that two small electrodes 
should be chosen, and that they should be well wetted and pressed 
firmly upon the trunk of the nerve at the two ends of that portion 
which is to be affected. Again, in applying electric currents to muscles 
it is found that if the currents be sent through the body of the muscles, 
only very imperfect and partial contractions occur, unless indeed the 
currents be excessively strong. Duchenne was the first to discover 







ELECTRICITY. 


83 


that when one pole is placed over certain spots or points in the muscle, 
violent general spasms of the muscle are produced by currents usually 
too feeble to elicit a distinct response. To these places the name of 
motor points has been given. These motor points correspond to the 
position at which the supplying nerve enters the muscle. When it is 
desirable to affect chiefly or solely a given motor point, it is evident 
that one small well-wetted electrode should be pressed firmly over the 
motor point, and another large sponge electrode placed at some little 
distance from it, in the manner which has already been explained. 

For certain purposes, to be hereafter explained, it is often desirable 
to affect chiefly the skin by the electric current. Under these circum¬ 
stances the skin should be well dried. It then offers so great a resist¬ 
ance that only currents of considerable strength are able to force their 
way through, and even these currents, taking advantage of the natural 
apertures formed by the sweat- and other glands, are broken up into a 
number of branch currents. The galvanic current reaches the internal 
structures in a great number of small streams very much reduced in 
power by the resistance they have overcome. If the second pole of 
the battery be a large well-wetted disk or sponge at a distant part of 
the body, it is evident that these branch currents will separate and 
subdivide in such a way that their effect upon the deeper structures 
will be almost entirely lost. 

It is a principle in physics that electricity upon points does not 
strictly obey Ohm’s law, but the force accumulates on the extreme end 
of the point until its density is excessive, and its self-repulsive power 
becomes so great as to overcome all resistance, and to break off highly 
electrified particles of the conductor, which fly off through the air. It 
is this that renders the so-called “ electric brush” so energetic in its 
action on the skin. This instrument consists of a number of wires 
united in the form of a cylindrical brush and connected with one pole 
of the battery; when this is brought in contact with the skin of a 
person, on whom at some distance is placed the other large well-wetted 
electrode, each wire point offers a dense accumulation of electricity, 
which forces its way at all hazards through a minute portion of the 
skin. The whole current of course enters the deeper tissue in an infi¬ 
nite number of subdivisions, and consequently its effect in these tissues 
is reduced to a minimum. 

Physiological Action.— When a moderately strong current of 
galvanism is passed along a certain length or portion of a nerve, there 
appear between the two poles two zones of disturbed nerve-function, 
separated by a neutral point at which the nerve retains its normal 
condition. In the neighborhood of the positive pole the irritability of 
the nerve, and also its power of transmitting impulses, are diminished, 
while in the proximity of the negative pole these nerve-attributes 
are increased: to the condition of diminished activity the name of an- 
electronus has been applied, while that of increased activity has been 


84 


ELECTRICITY. 


called katelectronus. Thus, in Fig. 6, cn equals the nerve; -f -p and 
— p, the positive and negative poles respectively; np, the point at 
which the function of the nerve remains normal, with the zone of 
anelectronus (a) on the one side, and that of katelectronus (k) on 
the other. The longer the current continues, and the more intense it 
is, the more does the zone of anelectronus gain upon that of katelec¬ 
tronus, or, in other words, the more closely does the neutral point (np) 
approach the negative pole (— p). Consequently, when a strong cur¬ 
rent has passed for a length of time through a nerve, the zone of kat¬ 
electronus is a very short one, confined to the immediate vicinity of the 
negative pole. 

When the particles of a motor nerve pass from a state of inertia 
to one of motility,— i.e., from one of diminished to one of increased 
excitability,—the nerve is momentarily excited, and gives origin to an 
impulse. Therefore, when anelectronus disappears in a nerve,— i.e., 
when a condition of diminished activity becomes one of normal activity, 
—an impulse is generated just as certainly as when katelectronus— 
i.e., increased functional activity—appears in a nerve previously normal. 

Suppose (Fig. 6) cn represents a nerve, and m the muscle to which 
it is distributed. If, then, a downward current be applied to this nerve, 

Fig. 6. 



it is plain, -j-p being the positive pole and —p the negative, that a will 
be the zone of anelectronus, np the neutral point, and k the zone of 
katelectronus. When the circuit is closed in obedience to the law 
already enunciated, an impulse starts from k, and, in order to reach m, 
has to pass only through the stretch of normal nerve between —p 
and m. Therefore this impulse of circuit-closure reaches the muscle 
unimpaired. 

Again, when the circuit is broken, the impulse which is generated 
in a, in order to reach the muscle travels only through the zone k, whose 
conducting-power is increased, and a portion of normal nerve; conse¬ 
quently it also reaches the muscle unimpaired. It is plain, then, that 
with descending currents strong movements must be induced, both at the 
making and at the breaking of the circuit. 

With ascending currents the results are different. Thus, in Fig. 7, 
cn = nerve; m = muscle; -f -p = positive pole; —p = negative pole; 


Fig. 7. 



np = neutral point; a = zone of anelectronus; k = zone of katelec¬ 
tronus. Now, it is plain that the impulse generated in k at the closing 







ELECTRICITY. 


85 


of the circuit must pass through a, the zone of diminished conducting- 
power, in order to reach m. Consequently, with the ascending current 
the contractions of circuit-closure are very feeble, or are altogether 
wanting. When, however, the circuit is broken, the impulse generated 
in a reaches the muscle m unimpaired. 

Without occupying more space with a discussion of the subject of 
electrotonus, but contenting myself with the statement that these 
facts and reasonings apply especially to such currents of moderate 
strength as are with propriety employed in therapeutics, it is plain 
that descending currents ought to be more efficient in inducing con¬ 
tractions than are ascending currents. What science thus has discov¬ 
ered, clinical medicine has also found out: descending currents are in 
practice found to be more powerful than ascending currents. 

From what has been already said, it is so evident as scarcely to need 
further demonstration that the breaking of a current running in one 
direction must render the nerve more sensitive to the closure of a cur¬ 
rent running in the opposite direction, but less sensitive to the closure 
of a current running in the same direction; for when the currents pass 
in opposite directions anelectronus suddenly becomes katelectronus, 
— i.e.., that which was below normal suddenly becomes above normal, 
—while with parallel currents anelectronus remains anelectronus. 

To make this more clear, however, Fig. 8 may be employed. In it 
the letters have the same significance as in those previously used, while 
the arrows on the side of the lettering represent the direction of the 
current to which the lettering applies. The downward current is sup¬ 
posed to be broken, and to be followed instantly by the upward: of 
course the upper, a, changes into k, and a doubly powerful impulse is 
sent down to m. Now the upward current is broken, and the down¬ 
ward sent through the nerve; at once the lower a becomes k, and m 
receives again a doubly powerful impulse. 

Fig. 8. 



The practical application of this reasoning is a very apt one. It 
becomes, in the first place, very plain why the secondary to-and-fro 
current of the induction coil has so much more power over muscles 
than has the primary induced current or the chemical current, as 
ordinarily applied. 

If, however, instead of the chemical current being simply inter¬ 
rupted, its polarity be suddenly reversed at brief intervals, all the 
effects of the to-and-fro induction current upon healthy muscle are 
obtained. More than this, for reasons to be hereafter adduced, in cer- 









86 


ELECTRICITY. 


tain muscular paralyses I have found that muscles which fail to respond 
to all other currents respond readily to a very slow to-and-fro chemical 
current. 

Having obtained an idea of the manner in which galvanic currents 
produce muscular contraction, it is next in order to study their influence 
upon diseased muscles. 

If a muscle by destruction of its supplying nerve be cut off from all 
spinal influence, it or its nerve rapidly undergoes a degeneration.* In 
the course of a very few days it will be found upon testing that the 
muscle no longer responds to a rapidly-interrupted faradic current, but 
does respond to such current when slowly interrupted; a couple of days 
later, and the muscle fails to contract to the most powerful and most 
slowly-interrupted induced currents. When, however, the continued 
current is applied, and is very slowly interrupted, or, better still, re¬ 
versed at intervals of one or two seconds, contractions are produced. 
It is this fact that has led to the belief that there is some intrinsic and 
inscrutable difference between the induced current and the chemical cur¬ 
rent. But time is an element required for the propagation of any 
force. If the hand be passed rapidly through a flame, the latter is not 
felt; if the hand move more slowly, a sensation of warmth is per¬ 
ceived; if the motion be still slower, this sensation becomes pain. 
How, if the hand be partially anaesthetic from disease, in order for 
the sensation of warmth to be perceived motion must be much slower 
than in the first instance. In other words, more time is required for 
the partially paralyzed sensory nerve to perceive heat than for the 
normal nerve to do so. What is true of the sensory nerve is true also 
of the motor nerve. It does not respond so quickly to stimuli when 
partially paralyzed as when normal. The muscle first loses its power 
of responding to those galvanic currents which are excessively rapid, 
then to those which are less so, and finally to all induced currents, 
because from their very nature these currents, even when slowest, last 
but a fraction of a second. The chemical current may be continued 
for any length of time at the will of the operator, who is thus enabled 
to act upon a muscle whose nerve has become so insensitive that it fails 
to perceive the flash of faradic galvanism. 

The proof of this somewhat dogmatic reasoning is to be found in 
the fact that the rapidly-interrupted chemical current is no more able 
to affect the diseased muscle than is the rapidly-interrupted faradic 
current, as I have proved over and over again in various forms of 
paralysis. That there is no difference between the chemical and the 
induced currents in their chemical action, except in so far as their 
influence is affected by the duration of their passage and the to-and- 
fro character of many induced currents, is abundantly proved by the 
“ Gramme magneto-electric machines,” in which an induced current is 


* The peculiar electrical reactions of a degenerating muscle are given in detail on p. 88. 



ELECTRICITY. 


87 


obtained with almost infinitely rapid interruptions and running only 
in one direction. With this current all the phenomena of chemical 
decomposition, etc., are obtained, and no doubt the effects of the con¬ 
tinued chemical current upon the human frame would be producible. 

Therapeutic Application.— Most of the therapeutic applications 
of electricity are considered in this book under special headings, but 
it seems proper at this place to call attention to the use of the current 
for the relief of various local rheumatic affections. In subacute or 
chronic muscular rheumatism faradization is often of great service, and 
even in rheumatic diseases of the joints it sometimes brings marked 
relief. When the symptoms are acutely inflammatory they must first 
be subdued by suitable measures; but when they are subacute the cur¬ 
rent may be employed at the beginning of the attack. It should be 
rapidly interrupted, and should be as strong as can be borne by the 
patient. The first seance should last but five minutes, but the time of 
application can be gradually protracted to fifteen or twenty minutes. 

Motor System .—Galvanic currents are employed in paralytic affec¬ 
tions for three distinct purposes,—namely, diagnosis, prognosis , and 
therapeusis. These I shall consider in the order in which they have 
been named. 

There are certain palsies, such as pseudo-muscular hypertrophy, in 
which the muscular structure is so destroyed independently of any 
involvement of the nervous system that no response to the galvanic 
current is possible. All of these palsies are, however, essentially ex¬ 
ceedingly chronic, and their diagnosis is to be made out chiefly by a 
microscopical examination of the muscles themselves. As electricity 
does not come into play in the diagnosis of these cases, I shall not say 
more about them. It is otherwise with suddenly-developed paralysis 
in which the history does not point to any immediate cause, such as 
diphtheria. Often, in such cases, galvanism is of great diagnostic 
value. As stated previously, when a muscle is entirely deprived of 
the influence of the spinal centres it rapidly loses its electro-contrac¬ 
tility, whereas, if a muscle be paralyzed from a lesion of such character 
or position as not to interfere between it and the trophic cells of the 
cord, it maintains its integrity for many weeks. When a muscle is 
degenerating for want of spinal influence, it first loses its power of 
responding to rapidly-interrupted faradic or chemical currents, then 
to slowly-interrupted faradic currents, then to slowly-interrupted chem- • 
ical currents, and lastly to slowly-reversed chemical currents. At this 
time occurs with the galvanic current the so-called “ reaction of degen¬ 
eration ,” first discovered by Brenner, and since elaborated by Erb 
( Zicmssen's Encyc., xi. 273) and G. B. Massey (Med. News, Feb. 1883, 
p. 124). To comprehend this, it must be remembered that it is obtain¬ 
able only by applying the electrode to the muscle: if the electrode be 
applied to a nerve-trunk of a degenerating muscle it will be found that 
reaction is diminished in quantity but not altered in quality. When a 


88 


ELECTRICITY. 


galvanic current of only moderate strength is used, and the negative 
pole (cathode) placed over the normal muscle but not over its motor 
point, a strong contraction occurs at the closure of the circuit; when, 
however, the positive pole (anode) is placed over the normal muscle, 
the contraction is much less; in neither case is there any contrac¬ 
tion when the circuit is broken : in other words, with the normal 
muscle and a feeble current we obtain good cathodal closing contrac¬ 
tion, slight anodal closing contraction, and no motion whatever at 
either cathodal opening or anodal opening. When a current of suf¬ 
ficient power is used, opening contractions are produced, and the 
anodal contraction is greater than the cathodal. The “reaction of 
degeneration” consists merely in a more or less perfect reversal of the 
above formula. The anodal (positive pole) closure then causes a 
stronger contraction than the cathodal (negative pole) closure. When 
there is only a slight degree of degeneration present, there is a corre¬ 
spondingly slight increase of anodal closing over cathodal closing con¬ 
traction. A minimum degeneration would be indicated by an equality 
of the two closing contractions. 


These alterations in the electrical relations of a degenerating muscle 
are readily formulated, and in this way are perhaps more readily 
grasped by the student. The symbols are as follows: An Cl C repre¬ 
sents anodal dosing contraction; An O C represents anodal opening 
contraction; K Cl C represents cathodal closing contraction; K OC 
represents cathodal opening contraction; < represents is less than; 
> represents is more than (the point of the < being towards the lesser 
quantity). Then the formulas are : 

An Cl C < Ca Cl C 


An O C > Ca O C 
An Cl C = Ca Cl C 
An O C = Ca Cl C 
An Cl C > Ca Cl C 
An O C < Ca O C 


muscle normal. 


muscle in first stage of degeneration. 


} 


muscle in a more advanced stage of degener¬ 
ation. 

After the latter Reactions of Degeneration (De R of some authors) 
have been established, if the muscle continues to undergo change, the 
galvanic irritability slowly diminishes, stronger and stronger currents 
being required to produce an effect. When a certain stage is reached, 
all reactions cease, save a feeble An Cl C, and at last this is lost and 
the muscle responds not at all. When recovery occurs, the electrical 
reactions of the muscle pass upwards along the pathway they have 
descended. 

The practical importance of the Reaction of Degeneration is greatly 
lessened by the circumstance that its demonstration usually requires 
much skill and patience,* and that it probably is never present when a 


* Dr. Massey gives the following directions as to the method of making the test: 
“ Having placed one well-moistened electrode over the muscle to be tested, and the other in 



ELECTRICITY. 


89 


muscle still retains its integrity as regards the faradic current. For 
the purposes of the practitioner, the failure of response to the latter 
current is the best test as to the condition of a muscle. When a muscle 
loses its power of responding to the rapidly-interrupted faradic current 
in a week or ten days after the occurrence of paralysis, whether the 
reaction of degeneration can or cannot be satisfactorily demonstrated, 
the inference is very positive that the lesion either is one of the nerve- 
trunk, or, if of a nerve-centre, is of such a character as seriously to 
involve the trophic cells of the spinal cord. If a few days later such 
muscle is unable to respond to any faradic current, this inference 
becomes a certainty. Under these circumstances, the possible lesion 
is narrowed down to infantile paralysis, a conceivable destructive 
myelitis, and an affection of a nerve-trunk. 

A myelitis so rapid and severe as to destroy in a few days a portion 
of the spinal cord, and consequently the electro-contractility of its trib¬ 
utary muscles, is exceedingly rare, and, if it occurred, could only be 
confounded with spinal congestion complicated with hemorrhage. In 
infantile palsy the nature of the case is usually but too apparent, al¬ 
though the muscles often lose their electro-contractility as quickly as 
when a nerve-trunk is severed. Practically, therefore, very rarely is 
there any difficulty in recognizing the seat of the lesion in acute or¬ 
ganic palsies by means of the galvanic test. It may be laid down as a 
practical rule that when in the adult a muscle loses to a sensible degree in 
a few days its electro-contractility , the lesion is in a nerve-trunk. In recog¬ 
nizing, however, these peripheral palsies, it must not be forgotten that 
the injury to the nerve may be very deeply situated,—even within the 
membranes or substance of the nerve-centres. This is especially to be 
borne in mind when it is a cerebral nerve that is affected. Thus, a 
tumor situated in a superficial portion of the brain may press upon the 
fibres of a nerve just as they are collecting together previous to leav¬ 
ing the brain, and the result will be a palsy which is really a peripheral 
one, although the tumor is in the nerve-centre. A similar thing may 
happen to the spinal cord: thus, I have seen, in spinal congestion 
giving origin to meningeal apoplexy, rapid and total destruction of the 
electro-muscular contractility in the lower extremities, from the pressure 
of the clots upon the cauda equina. 

The persistence of the muscular contractility intact for some weeks 
after the occurrence of a palsy depending upon an organic lesion proves 

some carefully-selected point of departure, it next becomes necessary to close and open the 
circuit properly. For this purpose nothing is in any way comparable to a pedal rheotome, 
a simple mechanism worked by the foot; it is, in fact, a necessity whenever the services of 
an assistant cannot be obtained, as a steady application of the electrodes is essential in many 
delicate cases,—even the slightest movement produced by the working of the hand-current- 
breaker being confusing. If the pedal rheotome also contain a commutator, worked by the 
foot, for changing the poles while still in situ, its handiness will be greatly increased. The 
clock-work current-breakers usually furnished by instrument-makers are totally unfit for 
diagnostic purposes.” 



90 


ELECTRICITY. 


that the disease is of cerebral origin, or, being spinal, is of such nature 
as not to compromise seriously the trophic nerves of the cord. 

In applying these rules, it must not be forgotten that whenever a 
muscle is not used it loses its contractile power, so that even in paraly¬ 
sis from cerebral hemorrhages the muscles finally degenerate, although 
this degeneration is rarely so complete as in peripheral palsies. It is 
not the fact of degeneration, but its degree, and especially the period 
of time which elapses between its occurrence and the commencement 
of the paralysis, that is the important factor in the diagnosis. In 
cerebral palsies no distinct loss of functional activity in the muscles is 
usually perceived sooner than six weeks after the onset of the attack ; 
and even after years have elapsed some response may often be elicited 
by strong slowly-interrupted or reversed currents. 

There are certain palsies in which the electro-muscular contractility 
is really or apparently above normal. Very frequently the excessive 
contractions produced are not so marked in the muscles to which the 
currents are applied as in other muscles, whose movements are in reality 
reflex in their nature. In all these cases the probabilities are that there 
is a condition of acute hyperaemia or of excessive functional irritability 
of the spinal cord. 

In regard to certain so-called functional palsies: in diphtheritic paraly¬ 
sis the irritability of the muscles is often diminished and sometimes 
destroyed; in lead palsy it is generally lost, and, curiously enough, 
according to my own observation the muscles may recover to a marked 
degree the power of voluntary motion, without a corresponding restora¬ 
tion of their normal electrical relations. 

In hysterical paralysis any aid to diagnosis is often of very great 
value; and it has been asserted that in this class of palsies the preser¬ 
vation of electro-contractility with loss of electro-sensibility is always 
present, and is of diagnostic import. My experience, nevertheless, is very 
positive that in hysterical palsy both electro-contractility and electro- 
sensibility are frequently normal. When, however, the paralyzed mus¬ 
cle responds to galvanic currents, and the patient is to a great extent, 
or altogether, insensible to their passage, a very positive diagnosis of 
hysteria may be given. The electro-contractility is never seriously 
compromised in hysterical palsy. 

In using galvanism as an aid in prognosis , the condition of the mus¬ 
cular contractility is always to be considered in conjunction with the 
nature of the lesion and the length of time it has existed. 

Taking first ordinary hemiplegia as the type of cerebral palsies, it 
must be borne in mind that the actual existent amount of paralysis 
is really the product of two essentially different factors. The nerve- 
centre is primarily damaged, and after a time the muscle also suffers 
loss of structural integrity from want of use. The restoration of the 
nerve-centre does not necessarily involve the restoration of the muscle, 
so that in a case of hemiplegia of some standing the cei-ebrum may 


ELECTRICITY. 


91 


have recovered itself partially or entirely, and yet the muscle be in 
such a state of degeneration as to be unable to respond to the impulse 
transmitted to it from the nerve-centre. 

Under these circumstances, galvanic treatment, although unable to 
affect the nerve-centres to any extent, does great good by restoring the 
muscular tone. It is manifestly impossible in such a case to determine 
before ti*eatment how far the nerve-centre has recovered itself, or, in 
other words, to what extent the existing paralysis is of centric and to 
what extent of muscular origin. When, in a case of apoplectic hemi¬ 
plegia, there is no recovery at all of the power of voluntary move¬ 
ment after the lapse of six weeks, the prospect of decided improvement 
from electrical treatment is very gloomy, because the probabilities are 
altogether in favor of the existence of a serious, persistent centric lesion. 
If, however, there is some motion, the probabilities of improvement are 
inversely proportionate to the structural health of the muscles: i.e., the 
worse the state of the muscle the better the expectation of relief. If the 
tone and the electro-contractility of the muscles are normal, the centric 
factor is the chief one in the production of the paralysis, and little good 
is to be achieved by the use of the galvanic current. On the other hand, 
if the muscles have undergone a very decided degeneration, much good 
is to be expected. No hopes of absolute cure should, however, be held 
out, because, in the great majority of cases, after the muscles have 
been fully restored the nerve-centre is found to be more or less dam¬ 
aged. The improvement under the use of electricity is usually at first 
rapid, but after a time ceases altogether, because, the muscles having 
recovered their tone, it is not possible to affect to any great extent the 
sole remaining cause of the paralysis,— i.e., the centric lesion. Under 
these circumstances it is useless to continue treatment. 

In infantile •paralysis , early in the attack the galvanic current is 
of little value in determining the prognosis, except that the general 
law is, that the more rapidly electro-contractility is lost, the more seri¬ 
ous is the case. In advanced cases, the dui’ation of the attack and the 
condition of the electro-contractility in the muscles are both to be con¬ 
sidered. If no response at all to an electric current can be obtained, 
the prognosis is always very grave; although even under such circum¬ 
stances a decided improvement has occurred in a small percentage of 
the cases I have treated. If the case be an old one, the preservation 
of some degree of electro-contractility indicates that the structural 
lesion in the cord is not a fatal one; and as, under these circumstances, 
the muscles can always be more or less perfectly restored, the prospect 
of improvement is very good. The preservation of electro-contractility 
late in the disorder, when the centric lesion is no longer progressing, is 
of much more import than it is in the first few weeks or months of the 
case, when the central trouble may be increasing. 

In peripheral palsies the prognosis depends rather upon the nature 
of the nerve-lesion than upon the condition of the muscle; but it must 


92 


ELECTRICITY. 


be remembered that when a muscle has absolutely lost its power of 
responding to any electrical current its restoration is always a matter 
of difficulty and of some doubt. 

In regard to therapeusis, the first point to be determined in acute 
cases is, very often, when to commence electrical treatment. When the 
lesion is of such nature as not to provoke any irritation of the nerve- 
centre, no time should be lost. Thus, if a man is unable to use his 
arm because he has slept with it under his head and thereby paralyzed 
the nerve by pressure, galvanism should be at once employed. 

When, however, the lesion is of such character as of necessity to 
irritate the nerve-centres, the case is different. The local stimulation 
of the peripheral nerve-fibres by the electrical current does, in some 
way not yet definitely understood, affect the nutrition of the nerve- 
centres ; and when these nerve-centres are in a state of active excite¬ 
ment or inflammation, a peripheral galvanic irritation may do serious 
injury. Hence the rule that when an acute palsy is connected with 
active irritation of the nerve-centres, galvanism should not be used 
upon the muscles until the centric disturbance has subsided. Thus, in 
hemiplegia from cerebral hemorrhage the muscles must be allowed to 
rest not only until all symptoms of centric irritation have passed away, 
but also until the brain has become so accustomed to the clot that the 
latter no longer acts as a foreign body. It is usually from three to 
six weeks before electricity can be used with advantage in these cases. 
Again, in acute cerebritis, cerebral or spinal meningitis , and myelitis , the 
employment of galvanic currents should be strictly forbidden until a 
stage is reached when the effects of the inflammation, and not the 
inflammation itself, are to be dealt with. 

When it has been decided to commence the use of galvanism, it is 
next to be determined what current shall be employed. It has already 
been shown that there are no inherent mysterious differences in the 
various currents; yet there is a practical difference, and the clinical 
rule of choice is, Always select that current which produces the greatest 
number of muscular contractions with the least amount of pain; trying 
the rapidly-interrupted faradic or the rapidly-interrupted chemical 
current and the slowly-interrupted faradic or the slowly-interrupted 
chemical current, and always, when these fail to elicit response, the 
slowly-reversed chemical current, which, if necessary, may be increased 
in strength until the patient can no longer bear the pain. 

The current having been selected, the individual muscles must be 
galvanized at each seance. 

After what has been said previously, it is not necessary to speak 
at this point as to the best methods of applying the currents to the 
muscles, but only to insist upon the fact that it is not so much the 
electricity as the contractions induced by it that benefit the palsied 
parts, and that consequently the electro-motor points of the muscles 
should always be separately reached. The diagrams given in the Ap- 


ELECTRICITY. 


93 


pendix will point out more clearly than would pages of description the 
approximate positions of the motor points, which vary somewhat in 
their location in various individuals. Some deep-seated muscles we 
are not able to reach directly, but we can reach them indirectly by 
galvanizing the nerves which supply them. 

There are certain precautionary rules which must never be lost 
sight of in the galvanic treatment of palsies. Pain is an evil, and its 
infliction is always to be avoided as far as possible. Hence the rule 
never to use stronger currents than is necessary. It is very possible to 
fatigue a healthy muscle, much more a diseased one. A weak muscle 
may be greatly injured by being over-fatigued. Hence the rule that 
currents are not to be applied to muscles sufficiently long at a time to 
induce fatigue. In general, an electrical seance should last from ten to 
twenty minutes, no one muscle being subjected to the currents for more 
than five minutes, and it may be repeated daily, or three times a week. 

Sensory System. —Affections of the sensory nerves are of three kinds, 
—pain, hypersesthesia, and anaesthesia. There are, of course, distinct 
states or disorders, which may exist separately or conjointly: as an 
instance of the coexistence of pain and anaesthesia may be mentioned 
the anaesthesia dolorosa of Romberg. The use of electricity for the 
relief of these disorders is almost entirely empirical,—indeed, is often 
purely experimental in an individual case, as no clinical laws regulating 
the use or enabling us to decide as to the applicability of the’ agency 
have as yet been worked out. 

It may be laid down, however, as an axiom, that the galvanic cur¬ 
rent is powerless to relieve the pain of phlegmonous inflammations, and 
that its use should be restricted chiefly to nervous pain or neuralgia. 
It is also true that the cui’rents are possessed of no therapeutic power 
over neuralgia dependent upon central organic lesions; this is also prob¬ 
ably true of such neuralgias as migraine, malarial hemicrania, and toxic 
neuralgias, in which, although there is no perceptible organic lesion, 
there is some deep-seated, inherent deficiency either in the central 
nervous system or in the constitution or condition of the patient. 

In rheumatic neuralgias, such as sciatica, electricity sometimes does 
great good, but perhaps more often fails. I have seen it effect the 
greatest good, and I have seen it aggi’avate the disorder. My experi¬ 
ence has not been sufficient to allow me to speak authoritatively, but 
it appears to indicate that the currents are most successful when the 
stage of acute inflammation is past and when the pain is maintained 
by some persistent condition or habit of the nerve-trunk. In regard 
to the selection of the current, my experience is that it must be purely 
empirical. The most usually successful is a very mild (four to eight 
cells) chemical current, which should be passed steadily for ten minutes 
down the nerves. It should not be so strong as to give actual pain, 
and must not be interrupted. As in the great majority of cases this 
method of application yields the best results, it should always be tried 


94 


ELECTRICITY. 


first. When it does good, it nearly always affords relief after, at the 
most, two or three sittings. Some cases receive most benefit from a 
rapidly-interrupted faradic current, which should therefore be tried if 
the continuous current fails. To the employment of electricity should 
of course always be added the proper constitutional treatment of the 
case. 

In hysteria , in some cases whose nature is very obscure, and rarely 
as a sequela or result of a serious cerebral or spinal lesion which may 
have been more or less completely recovered from, there exist local 
ancesthesias of the skin. When these are not dependent upon a too 
serious organic lesion, they are often very much benefited, or even 
cured, by the use of the electric brush. This should be large and com¬ 
posed of fine wii’es, while the other electrode should consist of a large, 
well-wetted sponge, placed upon a distant part of the body. Either 
the faradic or the chemical current may be employed; in either ease it 
should be a very strong one. 

Application to the Nerve-Centres, and Use as a Tonic.— Gal¬ 
vanism in various forms has been applied locally to the nerve-centres in 
various diseases. In regard to the brain, I have never yet met with 
any clear clinical evidence of good having been accomplished; and, 
with our present physiological knowledge, it is difficult to imagine in 
what way or under what circumstances cerebral galvanization can 
produce good results. On the other hand, harm certainly has been 
wrought by the application of strong currents to the head. Galvanic 
currents passed through the brain can act only as irritants, and I agree 
entirely with the dictum of Cyon ( Principes d' Electrotherapies Paris, 
1873), that galvanization of the head ought to be abandoned. 

An enormous amount of influence in all sorts of diseases has been 
claimed for the so-called galvanization of the sympathetic. In this appli¬ 
cation an olive-shaped electrode is pressed firmly into the auriculo- 
maxillary fossa, while a large sponge electrode is placed over or by 
the side of the sixth and seventh cervical vertebrae. For anatomical 
reasons, I do not believe it possible by this method to affect the upper 
cervical sympathetic ganglion; and the physiological and clinical evi¬ 
dence seems to me to point to the same conclusion. The ganglion 
is placed deeply beneath the carotid artery, and so situated that any 
current traversing it en route to the other pole, as usually applied, 
would have to pass through the vertebrae. The laws of electrical con¬ 
duction, however, show that the currents would seek the routes of 
least resistance, so that it is a priori improbable that any appreciable 
portion of the galvanism would pass through the ganglion. 

Leaving all this aside, the physiological proof that the currents of 
appreciable power do not reach the ganglion are, to my mind, abso¬ 
lute. When the slightest galvanic stimulus is applied to the bared 
ganglion, the results which follow are uniform, constant, and so ap¬ 
parent that a child can see them: they are dilatation of the pupil, and 


ELECTRICITY. 


95 


contraction of the vessels of the eye, ear, etc., and nothing more. These 
results do not follow the application of the currents in man, as above 
described. It has been asserted that the vessels of the retina have 
been seen to contract; but Professor William F. Norris, one of the best 
ophthalmologists in the country, has very closely observed the retinal 
vessels under these circumstances, and has never been able to detect 
the slightest change. Moreover, some of the observers who have seen 
the vessels alter state that they dilate, while others affirm that they 
contract, or that they sometimes contract and sometimes dilate. If the 
vessels change under the influence of the current, why does not the 
pupil? Any unprejudiced observer can be convinced at once that it 
does not alter, and any prejudiced and not very skilful ophthalmologist 
may find in the retinal vessels what he expects. Drs. Beard and Rock¬ 
well strongly insist upon the possibility of galvanizing the cervical 
sympathetic, yet they acknowledge (loc. cit ., p. 129) “ that the ordinary 
therapeutical measures for electrizing the sympathetics do not produce 
the same effects as electrizing the ganglia.” This being so, it would 
seem unnecessary to discuss the subject further; yet I shall analyze 
somewhat the evidence upon which the gentlemen mentioned, along 
with other electro-therapeutists, rest an opinion so seemingly opposed 
to all scientific induction. This evidence, as founded on the large series 
of experiments of Drs. Beard and Rockwell, is embraced in the follow¬ 
ing paragraphs: 

First. The alleged action on the retinal vessels. 

Second. A hypnotic effect was sometimes perceptible, but only in 
the very nervous and impressionable. 

Third. A sensible perspiration was caused when very strong cur- 
rents were used. 

Fourth. The pulse was sometimes accelerated, sometimes slackened. 

In regard to the evidence contained in the first paragraph: as 
already stated, the results of observations are altogether contradictory, 
even Beard and Rockwell stating that “ much seemed to depend on the 
temperament and condition of the individual; what would cause con¬ 
traction in one would cause dilatation in another.” The changes in the 
retinal vessels could not, under these circumstances, have been due to 
an action of the galvanism upon a ganglion, stimulation of which 
always produces contraction of the vessels: evidently, if alterations 
of the vessels really occurred, they were the results of physical or 
other influences, and not directly due to the galvanic current. 

As none of the phenomena mentioned in the second, third, and 
fourth propositions are produced when the bared ganglia is galvanized, 
and as all of them are producible by pain or nervous excitement, it 
seems very plain that, like the asserted retinal changes, they must have 
had their origin in the psychical disturbance of observer or patient. 

Very great therapeutic value has been attached by various writers 
to the effect of galvanization of the spinal cord. As in the case of 


96 


ELECTRICITY. 


the sympathetic, most opposite opinions are held by equally high 
authorities: one asserting that a downward spinal current dilates 
and an upward one contracts the vessels of the cord, while another 
strenuously insists that upward currents contract the vessels and 
downward currents dilate them. The same line of reasoning that has 
here been given in regard to the sympathetic nerve applies to the spinal 
cord. The infinitely weak current formed between a silver grooved 
director and a pair of iron forceps, moistened with the fluid of the 
body, will induce when applied to the bared cord very distinct evidences 
of functional excitement, in the form of spasms; and yet no current I 
have ever been able to apply to the spine in patients has caused a 
tremor in the muscles other than those of the back. If spinal cur¬ 
rents do good directly, I conceive it must be by an action upon the 
nerve-peripheries; for it is entirely possible that such an action may 
affect the nutrition of the cord. Moreover, in some of the diseases in 
which the measure has been practised with most success, the very great 
power of the emotions is notorious; and I conceive electricity often 
cures by acting on the mental or the moral nature. Of course the cure 
may be no less real and important on this account. In that peculiar 
affection allied to hysteria, variously known as spinal irritation , spinal 
anaemia , etc., I have seen the application of electricity to the back of 
the greatest service. Sometimes a rapidly-interrupted, strong faradic 
current has appeared to be most effectual; sometimes a moderate, con¬ 
tinuous chemical current has best suited the case. In spinal congestion. 
and in chronic spinal inflammations of all forms, I have used downward 
chemical currents in a large number of cases, but in every instance 
other measures were at the same time employed, and only in a very 
few cases has there been any definite evidence of the galvanism being 
of any service. From ten to twenty-five cells may be employed, the 
positive pole being applied for fifteen to twenty minutes upon the nape 
of the neck, and the negative over the coccyx or on the centre of the 
lumbar vertebra. 

It has recently been shown that galvanism has some tonic powers, 
and may be used as such in cases of simple debility or nervous exhaus¬ 
tion without any definite lesions. From what we know of its physio¬ 
logical action, it is reasonable to suppose that the force must be able to 
modify the circulation of every part that has muscular fibres in itself 
or in its blood-vessels; and such parts constitute the great bulk of the 
body. It has also been shown by Dr. S. Weir Mitchell that it is capable 
of temporarily elevating the general bodily temperature. Whether its 
action is solely by modifying the circulation and causing muscular 
contractions, or whether it has also a more direct influence upon the 
nutritive cell actions, is uncertain. Beard and Rockwell* employ two 


* A Practical Treatise on the Medical and Surgical Uses of Electricity. New York, 
ffm, Wood & Co., 1875. 



ELECTRICITY. 97 

methods of application, which they denominate general faradization 
and central galvanization, as follows : 

General Faradization. —In practising this, the patient should put 
the feet upon a copper plate, which serves as one electrode, or should 
have a large, moistened sponge placed over the coccyx, while a large 
sponge electrode is passed over the surface of the body. The movable 
electrode should be first placed upon the forehead, then back of the 
ears, a mild current being used. It may then be pressed firmly over 
the sixth and seventh cervical vertebrae, and a powerful current em¬ 
ployed ; then it should be passed to the posterior cervical triangle just 
by the posterior border of the sterno-cleido-mastoid muscle; then to 
the middle of the spine, where very strong currents are usually well 
borne; then down the chest to the pit of the stomach, and finally to 
the extremities. Beard and Rockwell give the following as the usual 
length and proportion of the seance: head, one minute; neck and 
cervical spine, four minutes; back, three minutes; abdomen, three 
minutes; upper and lower extremities, four minutes. 

In employing this method, at first the currents should not be too 
powerful, afterwards they should be made as strong as can be borne 
without pain. The seances should be held two or three times a week. 

Central Galvanization. —“The object in central galvanization is to 
bring the whole central nervous system—the brain, sympathetic and 
spinal cord, as well as the pneumogastric and depressor nerves—under 
the influence of the galvanic current. One pole (usually the negative) 
is placed at the epigastrium, while the other is passed over the forehead 
and top of the head, by the inner borders of the sterno-cleido-mastoid 
muscles, from the mastoid fossa to the sternum, at the nape of the neck, 
and down the entire length of the spine.” In applying the pole to the 
head, the hair should be wetted, or, if this be objected to, the applica¬ 
tion should be made to the top of the head, locally dampened, and over 
the prominences back of the ears. Care should be taken not to inter¬ 
rupt the current, and in increasing it to use the rheostat no oftener than 
is absolutely necessary. The seance should be repeated twice or three 
times a week, and should be arranged as follows: head, one to two 
minutes (six to eight cells); neck, both sides, one to five minutes (ten 
to fifteen cells); back, three to six minutes (ten to thirty cells). 

In regard to the choice of these plans, Beard and Rockwell affirm 
that general faradization is to be preferred where great muscular debility 
exists; central galvanization where there is rather a nervous exhaustion, 
as in hysteria and chorea , hypochondriasis , etc. In many cases the best 
effects are to be obtained by alternating the modes of application, either 
from day to day or from week to week. 

My own experience leads me to prefer decidedly the faradic current 
as a tonic. I believe that when properly used it does increase the 
activity of the circulation, probably by an influence upon the smaller 
vessels: it is further possible that it has a direct as well as an indirect 


98 


ELECTRICITY. 


influence upon the chemical movements of the general tissues. In 
order to get the best results, the seance should last from forty minutes 
to an hour, and should be divided into two parts. Thirty to forty 
minutes should be occupied in the first part, during which the effort 
is to bring into contraction all the muscles of the body. The current 
used should be a slowly-interrupted one, of such strength as to produce 
powerful muscular contractions. Beginning at one or other of the ex¬ 
tremities, and bearing constantly in mind the position of the motor 
points, the operator should go over the whole body, not forgetting the 
muscles of the chest, back, and abdomen. When the muscular system 
is sluggish the poles should be brought near enough to one another to 
bring the desired response. A plan which I have sometimes adopted 
with good results is to affix a large stationary electrode to the feet, or 
during part of the seance to the coccygeal region, and then to apply 
slowly and successively a smaller electrode to the motor points of the 
various muscles of the upper extremities, neck, trunk, and lower ex¬ 
tremities ; also to place for longer periods one electrode over the larger 
abdominal viscera. 


PART 


I I. 

DRUGS. 


A SKETCH OF THEIR NATURAL HISTORY AND PHARMACEUTICAL 
PREPARATIONS, WITH AN EXHAUSTIVE STUDY OF THEIR 
PHYSIOLOGICAL, THERAPEUTICAL, AND TOXICO¬ 
LOGICAL ACTIONS. 


PRELIMINARY CONSIDERATIONS. 

Although Pharmacy, or the science of preparing medicines, is 
entirely distinct from Therapeutics, or the science of the application 
of medicines to the cure of disease, it is evident that some acquaint¬ 
ance with the former is necessary to the correct appreciation of the 
latter. Further, the basis of each of these studies is a knowledge of 
Materia Medica, or the substances used as medicines. Pharmacology 
is the general term employed to embrace these three divisions. 

In every civilized country there is some recognized official list of 
drugs and their preparations, known as the Pharmacopoeia. In most 
places, this, being prepared with the sanction of the government, par¬ 
takes of the nature of a law, but in the United States conformity to it 
depends upon the voluntary action of the professions of Medicine and 
Pharmacy, by a representative convention of which it was originally 
prepared and is decennially revised. 

The preparations made from crude drugs are as follows: 

Abstracta. —Abstracts are powdered extracts so diluted with milk 
sugar that they are exactly twice the strength of the crude drug. 

Decocta.— Decoctions are made by boiling crude drugs for a greater 
or less time in water. It is evident that this method of preparing is 
ineligible when the active principle is volatile or is easily decomposed 
by heat, or when the drug contains much starch, whose extraction 
would make the preparation very thick and predispose it to rapid 
decomposition. The method is especially adapted to hard, woody sub- 

99 




100 


PRELIMINARY CONSIDER A TIONS. 


stances, and to those containing much albumen, which is coagulated by 
the boiling water and left in the original drug. 

Infusa.— Inf usions are made with water, either cold or hot, without 
boiling. They are prepared by maceration or by displacement. 

Liquores.— Solutions are preparations in which an active, non-volatile 
principle is dissolved in water. 

Aqile. — Waters are solutions of volatile principles in water. 

Mistur^e.— Mixtures are preparations in which one or more medici¬ 
nal substances are held in suspension in water. Of such nature are 
emulsions, in which some oily material is suspended by a gummy or an 
albuminous body. 

Mucilagines.— Mucilages are solutions of gummy substances in 
water. 

Syrupi.— Syrups are sugary liquids, the menstruum or basis of which 
is water, with, in some cases, vinegar or alcohol. 

Mellita. — Honeys are preparations whose basis is honey. 

Aceta.— Vinegars are preparations in which vinegar or dilute acetic 
acid is used as the menstruum. 

TiNCTURiE. — Tinctures are alcoholic solutions prepared by macera¬ 
tion or displacement from the crude drug, or by dissolving non-volatile 
principles. In some of them strong, in others dilute, alcohol is used. 

Spiritus. — Spirits are alcoholic solutions of volatile principles, made 
by direct solution or by distillation from the crude drugs. 

Vina.— Wines are preparations whose menstruum is wine. 

Glycerita. — Glycerites are preparations in which glycerin is the 
solvent. 

Olea Destillata.— Volatile , distilled , or ethereal oils are active prin¬ 
ciples obtained from plants by distillation or by other processes. They 
have no chemical relations with fixed oils, and are readily to be distin¬ 
guished by the fact that the stain which they leave upon paper dis¬ 
appears in a little time. They are usually composed either of carbon 
and hydrogen, or of carbon, hydrogen, and oxygen, to which, in the 
case of certain bad-smelling oils, sulphur is added. By oxidation they 
are converted into resinous compounds. They are all inflammable, 
usually of powerful odor, commonly, but not in all instances, lighter 
than water, slightly soluble in water, and freely soluble in petroleum 
benzin. By the destructive distillation of various organic substances 
are obtained products resembling somewhat volatile oils. These are 
the so-called empyreumatic oils. 

Oleata.— Oleates are solutions of definite principles in oleic acid. 

Oleoresin.e. — Oleoresins are concentrated preparations, composed 
generally of a volatile oil and a resin. They are really ethereal ex¬ 
tracts, made by the action of ether upon the crude drugs; in the case 
of ginger, a mixture of alcohol and ether is used. 

Succi.— Fresh juices are obtained by expression of the green plant, 
enough alcohol being added to preserve them. 


PRELIMINARY CONSIDERATIONS. 


101 


Extracta.— Solid extracts are of two kinds; one being prepared by 
the evaporation of the fresh juice, the other being made in various ways 
from the crude drug. 

Extracta Fluida.— Fluid extracts are very concentrated fluid prepa¬ 
rations, generally so made that one minim represents one grain of the 
crude drug. 

Resinas. — Resins are peculiar solid vegetable active principles, sol¬ 
uble in alcohol and insoluble in water, most of which are obtained by 
the precipitation of saturated tinctures with water. The majority of 
the officinal resins are purgatives. 

Confectiones.— Confections are medicinal substances beaten up with 
sugar into a pasty mass. 

Trochisci.— Troches , or lozenges , are gummy pellets or disks, so made 
as to dissolve slowly in the mouth. 

Suppositoria.— Suppositories are conical bodies, prepared for intro¬ 
duction into the rectum, where they melt with the heat of the body. 
Their basis is generally cacao butter. 

TJnguenta and Cerata.— Ointments and Cerates are fatty solid prep¬ 
arations for external use. The cerates containing wax ( 'cera ) are the 
firmer of the two. 

Emplastra.— Plasters are solid substances spread by the aid of heat 
upon muslin, skin, or other similar material, and of such nature as to 
be adhesive at the temperature of the body. 

Charts.— Papers are medicated leaves or sheets of paper for ex¬ 
ternal use. The only officinal papers are those of mustard, of nitrate 
of potassium, and of cantharides. 

Linimenta.— Liniments are liquid preparations, generally soapy or 
oily, and always intended to be applied externally by rubbing. 

The names of Pilule (Pills) and Pulveres ( Powders ) sufficiently 
indicate the character of the preparations. 

The effects of medicine are commonly divided into the primary and 
the secondary , or the immediate and the remote. An example will prob¬ 
ably show the difference between these in the briefest and most forcible 
manner. Thus, the immediate effect of a diuretic is increased urina¬ 
tion ; the secondary effect may be removal of serous effusion in some 
part of the body. It is evident that the latter is brought about not 
by the medicine itself, but by the changes it induces; the increased ex¬ 
cretion causing a diminution of the amount of the fluid in the blood¬ 
vessels, which in turn leads to absorption. 

The term or expression indication for a given remedy, being in con¬ 
stant use, ought to be distinctly understood; by it is meant the point¬ 
ings of nature, or, in other words, the evident needs of the system. 
Thus, hard faeces collected in the colon are an indication for a purgative 
of such character as will produce watery secretions to soften them. 
Relaxation in a part indicates a remedy that will awaken into new life 
the natural contractility of the part,— i.e., an astringent. Again, the 


102 


PRELIMINARY CONSIDERATIONS. 


suppression of secretion from over-excitement, or from irritation, is an 
indication for some drag which will allay irritation; while the same 
suppression, when dependent upon torpor or loss of cell-activity, will 
call for an excitant,—an irritant. The childish absurdity of treating 
symptoms by any such law as “similia similibus curantur” or “dissi- 
milia dissimilibus curantur” is at once apparent. The same symptoms 
may be the result of absolutely antagonistic conditions and require 
absolutely opposite treatment. Without occupying space with de¬ 
tails, one example will suffice. Either irritation or depression of the 
stomach may cause vomiting. Therefore in one case of vomiting a 
stomachic stimulant such as ipecacuanha, which when given freely in 
health will produce vomiting, may relieve the nausea because the de¬ 
pressed stomach needs a stimulation to bring it to the normal level; in 
another case a stomach which rejects food because it is irritated needs 
a sedative like bismuth, which in health will not produce vomiting. 
In the first case the law of similars seems to hold good, in the second 
the law of dissimilars appears to be dominant. A law of nature has no 
exceptions. If an alleged law of nature has exceptions it is not a law. 
If it were proved that under certain circumstances the earth without 
the intervention of any second force repels bodies, we should know 
that the alleged law of gravity is not a law. It is plain, therefore, that 
neither of the alleged therapeutic laws of similars or of dissimilars is, 
in truth, a law. They are the results of coincidence, the expressions of 
half truths. Symptoms are, indeed, but the surface-play of disease, 
and the rational therapeutist always seeks their hidden meaning. The 
conscientious physician refuses to practise upon homoeopathio, allo¬ 
pathic, or any other restricted basis, but gleans therapeutic knowledge 
from all sources, guiding himself as far as may be by the light of reason 
and science, but hesitating not to go beyond into the region of the un¬ 
known and uncertain when distinctly led by the lantern of empiricism. 

By far the greater number of remedies are absorbed into the blood, 
and thus find access to the part upon which they act. It is necessary, 
therefore, for them to be so placed that they can be taken into the 
blood-vessels. 

There are five paths of entrance for medicines into the circulation,— 
the stomach, the cellular tissue, the rectum, the skin, and the lungs. By 
far the most frequently employed of these is the stomach. It is evident 
that, in order to pass rapidly and readily into the absorbents, medicines 
must be in solution. When administered by the stomach, however, it 
is equally plain that solubility in an ordinary menstruum, such as water, 
is not a sine qua non , since the varying acidities, alkalinities, and or¬ 
ganic contents of the alimentary juices give to them a solvent power 
far above that of less complex and varying fluids. Thus, a medicine 
insoluble in water may be dissolved by the acids of the gastric juice, 
while another drug may owe its activity to its solution by the alkalies 
or by the fatty matters of the intestinal fluids. 


PRE LI MIN A R Y CONSIDER A TIONS. 


103 


The dissolving power of the rectal fluids is very slight: hence, in 
order to act efficiently, medicines when given by the rectum must be in 
solution or be readily soluble. Absorption, moreover, does not occur so 
rapidly from the rectum as from the stomach, and a longer time is there¬ 
fore needed to impress the system in this way. In the great majority 
of cases medicines are thus exhibited to obtain peculiar effects more or 
less local in character. Thus, an opium suppository is given in dysen¬ 
tery, or to quiet irritation of the genito-urinary organs. 

Medicines which are thrown into the subcutaneous tissue are said to 
be administered hypodermically. The syringe employed is provided 
with a sharp needle, which must be kept scrupulously clean and free 
from rust. The medicine must be in perfect solution and not too irri¬ 
tating. The advantages of this method of exhibition are promptness 
and certainty of action. If twenty minutes be required for the ab¬ 
sorption of a certain medicine from the stomach, forty minutes will be 
usually necessary when it is exhibited by the rectum, and five minutes 
when it is thrown into the subcutaneous tissue. The objections to the 
hypodermic method are, first, the danger of producing local inflamma¬ 
tion and abscesses; second, the possibility of throwing the whole mass 
directly into a vein and having it swept in concentrated form into the heart 
or nerve-centres. I have seen the injection of a sixth of a grain of mor¬ 
phine followed inside of a minute by complete unconsciousness, collapse, 
arrest of respiration, dropping of the jaw, and apparent death. The 
danger of such a mischance can be greatly lessened by withdrawing the 
point of the needle an eighth of an inch, after it has been plunged into 
the tissue. The local irritation produced by hypodermic injections has 
not only very frequently produced abscesses, but in not a few cases 
has caused fatal tetanus. Excessive irritation can be largely prevented 
by certain precautions, but there are many medicinal substances whose 
hypodermic employment might be advantageous were they not too irri¬ 
tant for such use. In all cases solution must be complete, and if the 
medicinal substance be of such nature that it is liable to be precipitated 
by alkalies, an excess of acid should be present in the water to prevent 
precipitation by the juices of the cellular tissue. An irritant which is 
rapidly taken up from the part may produce at first smarting and pain 
without creating any permanent irritation, but a small solid particle 
lying in the cellular tissue is almost sure to cause inflammation and 
abscess. All hypodermic injections should, therefore, be filtered before 
being used. It is of the utmost importance, even when a non-irritating 
substance is employed, that the injection should be absolutely antiseptic. 
No solution which has undergone any decomposition or contains any 
growth should be used at all. Ordinarily the solution should be freshly 
made. It should always be prepared with boiled or distilled water, 
and should usually have added to it half a drop of carbolic acid. This 
amount of carbolic acid when thrown into the cellular tissue, so far from 
increasing the irritation, has a distinct power of relieving pain by 


104 


PRELIMINARY CONSIDER A TIONS. 


virtue of its local anaesthetic influence; it also tends to prevent abscess, 
and has no perceptible effect upon the general system. When hypo¬ 
dermic solutions are intended to be kept, they should contain ten per cent, 
of carbolic acid with a drop or two of glycerin to every fifteen minims, 
which is the maximum amount that should be injected at one time. A 
considerable proportion of glycerin will throw out of solution most of 
the alkaloids, but when solution of the medicinal substance is distinctly 
favored by glycerin, as is the case with extracts, three or four drops of 
the glycerin should be added to the hypodermic solution. Not only the 
hypodermic needle but the whole syringe should be carefully disinfected 
before use with a strong solution of carbolic acid or other similar agent. 
The local influence of the injection is also influenced by the method 
in which it is given. If it be thrown directly under the skin, it may, 
by raising and tearing the skin from its attachment, so interfere with 
the supply of blood as to cause local irritation. The injection should, 
therefore, always be thrown deeply into the tissues, where it may diffuse 
itself. The arm, leg, or any other fleshy portion of the body may be 
selected, but there is reason for believing that the best place of injec¬ 
tion is the buttocks, about one and one-half inches behind the great 
trochanter. 

There are several ways in which medicinal principles are introduced 
through the skin, although the only one in common use is the appli¬ 
cation of medicated fatty preparations, either with or without fric¬ 
tion. Absorption takes place, of course, most rapidly at those places 
where the skin is thinnest,—the inside of the thighs, the surface of 
the abdomen, and especially the armpits. Almost the only remedy 
which in practical medicine is introduced into the system in this way is 
mercury. Absorption will take place through the skin from baths, but 
so slowly that this method is never made use of in the constitutional 
treatment of disease,—unless the sulphur baths, sometimes employed in 
rheumatism, impress the general system by absorption, which seems to 
me doubtful. Formerly, medicines were sometimes exhibited by placing 
them on blistered surfaces, beneath the raised cuticle; but, except in the 
instance of morphia, so much used in gastric disturbance, at present the 
endermic method is very rarely employed. 

In order for a medicine to be absorbed through the lungs in sufficient 
quantity to affect the general system it must be in the form of vapor 
or gas. 

For local purposes medicines are applied to various parts,—to the 
skin, to the ear, nares, fauces, stomach, larynx, lungs, rectum, vagina, 
urethra, etc. For the last three, liquid preparations known as injections, 
or solid ones known as suppositories, or, in case of the urethra, as bougies, 
or sometimes as urethral suppositories, are employed. 

For the purpose of making local applications to the respiratory 
organs, atomization is very commonly practised. Many forms of appa¬ 
ratus are in use, but the principle in all of them is the same. A 


PRELIMINARY CONSIDERATIONS. 


105 


rapid current of air, or of steam, is forcibly ejected from a horizontal 
pipe, through a capillary orifice, directly across a similar opening in a 
vertical tube. The rush of the vapor over this second orifice forms a 
vacuum; the fluid into which the base of the vertical tube is set, 
rushing up to fill this, is sucked or drawn out through the orifice, and 
as it emerges is broken into a fine spray, and is carried along by the 
current of air or steam into a mouth-piece, at which sits the patient. 
It cannot be gainsaid that in this way we are able to carry medicinal 
substances not merely into the larynx, but into the lungs themselves. 
Volatile medicines vaporized by heat are also sometimes employed in 
the treatment of lung-affections. 

There are various classes of agencies which so modify the action of 
drugs as to necessitate their consideration. Such are disease, climate, 
habit, temperament, idiosyncrasies, sex, age, time of administration, 
and emotions. 

Disease often fortifies the system against the action of remedies, so 
that the dose has to be greatly increased to obtain perceptible effects. 
Thus, pain or delirium tremens will interfere greatly with the produc¬ 
tion of narcotism by opium; or spinal disease with purgation. Disease 
may altogether prevent the action of a remedy. In all these cases two 
rules should never be lost sight of: fii’st, never give the medicine in 
such doses as would in health cause death ; second, always be sure, 
before giving large amounts, that the remedy will not make matters 
worse (as a drastic in intussusception). 

Climate , by producing physical habits or tendencies in the patient, 
often greatly influences the proper selection and dose of remedies. It 
is only necessary to allude to the great consumption of quinine in 
malarial regions as an example. 

Habit—including mode of life —seems to alter, as it were, the very 
constitution of man. Hot only does it give type to disease, by pro¬ 
ducing habitual plethora, or its opposite, but it also fortifies against the 
action of single remedies, or whole classes of them. Thus, in the 
opium-eater, a dose sufficiently large to kill an ordinary man serves 
only to gratify the cravings of appetite. Again, a man accustomed to 
one narcotic, as alcohol or opium, loses, to a greater or less degree, his 
susceptibility to all narcotic influence; and the patient whose bowels 
require daily to be moved by a cathartic finds that he reacts more 
and more slowly to medicines of that class. Again, a nervous system 
blunted by exposure and toil in the open air is far less susceptible to 
the action of remedies, and requires larger doses to influence it, than 
does the delicate organization of a woman weakened by indolence and 
luxury. 

Temperaments are peculiarities of organization characterizing classes 
of individuals; idiosyncrasies , peculiarities belonging to single individ¬ 
uals. This is scarcely the place to discuss the subject of temperaments, 
but it is allowable to state that while the phlegmatic person is no more 


106 


PREL1MINA R Y CO NS ID ERA TIONS. 


easily moved by medicinal than by other agencies, the nervous indi¬ 
vidual answers as quickly to the one as to the other. Idiosyncrasies 
seem at present to be beyond law. They are often very remarkable, 
and a knowledge of them is most important for the practitioner. 
Thus, a relative of the author’s is thrown into the most alarming 
fainting-fits by eating even so much butter as would be ordinarily used 
as a dressing for vegetables at dinner. Some persons are poisoned 
by the slightest touch of turpentine, others are frightfully salivated by 
a mere particle of a mercurial. These idiosyncrasies are numerous, 
cannot be foreseen, and are often very important: hence the necessity, 
in prescribing for an unfamiliar patient, of always asking as to his or 
her peculiarities. 

Sex modifies all diseases connected with the organs or the pro¬ 
cess of generation, but it also does more. Woman is more impres¬ 
sible, less robust, with less power of resisting external agencies, than 
is man. Consequently, the dose for her should, as a rule, be less than 
that for him. It is needless to remark here at length on the necessity 
for abstinence from strongly perturbing remedies during pregnancy or 
at menstrual periods. 

Age, of course, modifies materially the dose. The rule of Dr. 
Young, the one which is the most practical and generally useful, is 
to add twelve to the age and divide the age by the result. Thus, a 
child one year old would require one-thirteenth, one three years old 
three-fifteenths, of the amount necessary for an adult. Other rules 
have been invented, but the only one which is at all practical is the 
following, proposed by Dr. R. O. Cowling (American Practitioner , vol. i.): 

“ The proportionate dose for any age under adult life is represented 
by the number of the following birthday divided by twenty-four:” i.e., 
for one year it is ; for two years, ^ ; for three years, ^ ^; 

for five years, ^ = i; for eleven 37 -ears, |-| = etc. 

Professor Clarke (Boston Med. and Surg. Journ., 1872) has proposed 
a rule, which, although probably more accurate than either of those 
given, seems too cumbersome for ordinary purposes. It is based upon 
relative weights: 

“ Assuming the average weight of an adult to be one hundred and 
fifty pounds, for whom an appropriate dose is 1, or one drachm, the 
dose of most medicines must be increased or diminished in the propor¬ 
tion of the weight of the patient to that number of pounds. This pro¬ 
portion is represented by a fraction whose numerator is the patient’s 
weight and whose denominator is 150. If a child at birth weighs six 
pounds, the appropriate dose for it would be T | T , or ■srs-; if it weighs 
ten pounds, or A child two years old, weighing twenty pounds, 
would require ■^\ 5 , or about \ of an adult dose; or, more precisely, 

A person whose weight is two hundred pounds should have -££§-, or 1£ 
of an average adult dose.” 

It must never be lost sight of that children bear narcotics very 



PRELIMINA R Y CONSIDER A TIONS. 


107 


badly, and that the doses of such remedies for them should always be 
proportionally smaller than for the adult. 

Time of Administration .—Absorption takes place most rapidly in an 
emjffy stomach, and consequent^, when rapidity of action is desired, 
the medicine should be given under such circumstances. Thus, a pur¬ 
gative acts soonest when given before breakfast. Substances which 
are irritating to the stomach should always be administered not only 
properly diluted, but also when the viscus is filled by a mass of food, 
which may serve still further to lessen their concentration. Hence 
such remedies as iodine and arsenic are preferably exhibited after 
meals. On the other hand, whenever a remedy is especially intended 
to act on the mucous membrane of the stomach, it should be given 
when the viscus is empty. Again, some drugs, such as iron, are best 
dissolved by the acid gastric juice, and it is a matter of some impor¬ 
tance to place them in the stomach after eating, when the process of 
digestion is most vigorous. 

Mental Emotion .—Space is wanting to discuss at any length the 
influence of the imagination upon the action of remedies; and the 
reader must be referred to the delightful book of Dr. Tuke for illustra¬ 
tions. Suffice it to state that a positive announcement that a remedy 
will have a certain effect has often a most remarkable influence in pro¬ 
ducing that effect, especially on persons of nervous organization and 
of not too great culture to have faith. I have given a hypodermic 
injection of a grain of morphine to a man, inducing a degree of hyp¬ 
notism, and the next day, doubling the size of the injection but with¬ 
drawing all morphine, have caused a much more intense effect. 

On the Art of Prescribing Medicines.— In the practical use of 
remedies, very much depends upon the methods of their combination, 
and, so far as concerns the reputation of the physician, no little im¬ 
portance is to be attached to the mere prescription-writing. The 
recipes of the master are very widely seen, and he who is incorrect in 
the grammar or spelling of his English or Latin, or departs without 
reason from the traditional forms, lays himself open to ridicule, than 
which nothing is more damaging. A crooked, bad c-hirography is the 
traditional mark of literary fame; but absolute plainness should be a 
sine qua non in the writer of prescriptions. This should also apply to 
abbreviations: these should be of such a character as not only to be 
readily made out, but also to be so evident as to afford no shelter to 
the apothecary whose carelessness has led to serious -error. In the 
case of alkaloids and other powerful remedies, the chief name at least 
should be written in full. In writing the prescription, all the ingre¬ 
dients should first be put down, then the number of doses should be 
decided upon, and the individual amounts of each substance marked 
seriatim. It is a very good custom always to place first upon the list 
the strongest of the drugs employed. Without further comment, the 


108 


PRELIMINARY CONSIDERATIONS. 


following recipes are appended, simply as examples of the method of 
writing prescriptions: the first two only are given in full, with date, 
signature, etc.: 


John Smith, Esq. 

R Tr. cantharidis, f^ss; 

Tr. ferri chlor., f^ss. 

M. 

S.—Fifteen drops three times a day. 

July 1, 1888. S. W. W. 

John Jones, Esq. 

R Syr. scillae, 

Syr. senegae, aa f^i; 

Liq. morphinae sulph., f^ss; 

Syr. tolutan., q. s. ad f^iii. 

M. 

S.—Dessertspoonful four times a day. 
July 1, 1888. R. S. T. 

R 01. morrhuae, f^ii; 

01. amygdalae amarae, gtt. vi j 
Mucil. acaciae, f^iv. 

M. et ft. emuls. 

S.—Tablespoonful three times a day. 

R Cerat. oantharidis, q. s. 

Ft. emplastrum iii x iv une. 

S.—Use as directed. 

R Extr. chiratae, gr. xx ; 

Strychninae, gr. i; 

Ferri pulv., 

Oleores. piperis, gr. viii. 

M. et ft. mas. in pil. xx div. 

S.—One before meals. 


R Quininae sulph., gr. xxxvi; 

Tr. ferri chloridi, f^iii; 

Glycerini, 

Syrupi, aa f^iss. 

M. 

S.—Dessertspoonful after meals. 

R Hydrarg. chi. mitis, gr. vi; 

Sacchari, q. s. 

M. et ft. pulv. vi. 

S.—Use as directed. 

R Acidi tannici, oh 
Ft. pulv. in chart, vi div. 

S.—Use as directed. 

R Extr. colocynth. comp., gr. xii; 

Extr. belladonnae, gr. ii; 

Aloes, gr. xviii; 

01. caryophyl., gtt. xii. 

M. et ft. pil. xii. 

S.—One at bedtime. 

R Sennae, 3iii; 

Magnesii sulphatis, 

Mannse, aa 3 SS > 

Foeniculi, £i; 

Aquae bullientis, Oss. 

Macera per horam in vase leviter clauso et 
cola. 

S .—Black Draught. Dose.—A teacupful 

every six hours, until it operates.* 


The art of combining remedies is not a difficult one; but in prac¬ 
tice certain principles should not be lost sight of. Chief of these are, 
to prescribe as few remedies as possible, and to use no powerful drug 
without a very distinct idea of what it is intended to do. Whenever 
it is desired to give a powerful remedy in increasing doses until its 
physiological effect is produced, it should always be given by itself. 
Thus, it may be necessary to give arsenic so as to impress the system, 
at the same time that iron is indicated; but the two remedies should 
be given separately, so that the dose of either can be increased or 
diminished independently of the other. 

The principles of combination, formulated below, were long ago 


* These prescriptions are printed as usually written, with abbreviations. The full sen¬ 
tences of directions to the apothecary are:—Misce—Misce et fiat emulsio—Fiat emplastrum 
iii X iv unciarum—Misce et fiat massa in pilulas viginti dividendus—Misce et fiat pulveres 
sex—Fiat pulvis in chartulas sex dividendus—Misce et fiat pilulae duodecim. 




PRELIMINARY CONSIDERATIONS. 109 

enunciated by Dr. Paris, but are to-day as imperative as ever. Medi¬ 
cines are combined : 

First. To augment, correct, or modify the action of a medicine. 
Thus, purgatives act much more kindly when a number of them are 
united together. The chief reason of this probably is, that as dif¬ 
ferent remedies affect different portions of the gut, the whole intestine 
is best reached by a union of the diverse substances. It may take an 
intense irritation of the mucous membrane to purge as actively as does 
a mild irritation of both the mucous membrane and the muscular coat. 

There are powerful medicines which act similarly upon some parts 
of the organism but dissimilarly upon other parts. By combining such 
remedies powerful effects can be obtained at the points where the two 
lines of action cross each other, without influencing to a great extent 
other portions of the system. Thus, chloral produces sleep by its 
action upon the brain, and also has a distinct influence upon the heart, 
but none upon the intestinal tract. Morphine acts upon the brain, and 
does not influence the heart, but has a powerful effect upon the intes¬ 
tinal tract. By combining chloral and morphine we get an overwhelm¬ 
ing conjoined influence upon the brain in producing sleep with the least 
possible disturbance of the heart and of the intestinal tract. 

Secondly. To obtain the joint action of two or more diverse reme¬ 
dies. Thus, in a cough mixtui*e, morphine may be included to quiet the 
cough, while ipecacuanha and squill (in accordance with the first prin¬ 
ciple) are added to affect the mucous membrane. The application of 
this principle requires caution, or the practitioner will be led into that 
chief abomination, polypharmacy. It is worse than futile to attempt 
to prescribe for every symptom. It is the underlying cause of the dis¬ 
order or the understratum of bodily condition which must be sought 
out and prescribed for simply. 

Thirdly. To obtain a special combination which is really a new 
remedy, or which experience has shown acts almost as a new remedy. 
Thus, when to iodide of potassium in solution corrosive sublimate is 
added, a new chemical compound is formed, which experience has 
shown to be of great value in syphilitic diseases. Griffith’s anti-hectic 
mixture is another instance of the use of chemical changes, the proto¬ 
carbonate of iron being formed out of the sulphate of the metal and 
the carbonate of potassium. In the famous Dover’s powder no chem¬ 
ical change occurs, but the ordinary action of opium upon the skin is 
so enhanced that the combination may be looked upon almost as a new 
remedy. 

Fourthly. To afford a suitable form. Thus, acacia is added to 
make an emulsion, or confection of rose to make a pill. In the choice 
of excipients, care should be exercised to select a substance free from 
medical properties, having no chemical incompatibility with the medici¬ 
nal agent, and of suitable physical character. Bread-crumbs often 
make a good basis for pills; but with nitrate of silver they are chemi- 


110 


PRELIMINARY CONSIDERA TIONS. 


eally incompatible, on account of the chlorides in them. When writing 
a prescription, the utmost care should be taken to use such excipients 
that the combination shall not only be attractive to the eye, but also 
as little repulsive to the palate as may be. Whenever possible, the pill 
form should be employed with bitter or disagreeable medicines. The 
pill may be readily coated with silver-foil; tonic pills may be coated 
with iron by shaking or rolling them in ferri pulvis while soft and 
sticky. Sugar-coated pills and “ compressed pills” are liable to get 
so hard and insoluble that their use requires caution. In regard 
to mixtures, flavoring oils should be freely used, and the power of 
glycerin to conceal the disagreeable taste of many substances should 
be remembered. The recent introduction of capsules for the adminis¬ 
tration of nauseous medicines is a pharmaceutical improvement of the 
first rank. These capsules occur in two forms. Hard capsules are 
prepared to be filled extemporaneously. They can be made large 
enough to hold ten minims, although this size cannot be easily swal¬ 
lowed by every person without a little training. The soft, flexible 
capsules are filled by the manufacturing chemists. They can be readily 
swallowed by most persons up to the size of one drachm. Not only 
may solid preparations be given in capsules, but also essential oils, 
volatile liquids, fixed oils, and fluid extracts; indeed, almost any liquid 
the dose of which is not too large. 

Incompatibilities .—In combining remedies, the subject of incompati¬ 
bilities must never be lost sight of. The kinds of incompatibilities are 
two in number,—physiological and chemical. The first of these it 
would require large space to discuss fully, and any one familiar with 
the text of the book, if possessed of the slightest reasoning powers, 
can readily make all necessary deductions. 

In many works on materia medica long lists of chemical incompati¬ 
bilities are given in the accounts of individual drugs. These lists have 
seemed to me useless, as I have never met with a student who could 
commit and retain them. Moreover, they contain so much matter of 
no practical use that the valuable portion is hidden out of sight. A 
certain amount of chemical knowledge is essential to the student, and 
is not to be taught in a book like the present. He who would igno¬ 
rantly combine sulphuric acid and a carbonate needs to re-study his 
chemical text-book. All that I shall do here is to point out certain 
principles and a few especial reactions. The following rules may serve 
for a c;uide: 

Soluble salts which can by mutual decomposition form an insoluble 
compound will undergo such decomposition when they meet in solu¬ 
tion, and will precipitate, unless in some very rare instances, in which 
a double salt is formed. 

Soluble salts which are not capable of forming an insoluble salt 
never precipitate, and rarely undergo decomposition, when they meet 
in solution. 


PRELIMINARY CONSIDERA TIONS. 


Ill 


Mineral acids decompose salts of the weaker (carbonic, acetic, etc.) 
acids, and form ethers with alcohol and alcoholic preparations. 

Alkalies precipitate the alkaloids and the soluble non-alkaline me¬ 
tallic salts. 

G-lucosides , such as santonin and colocynthin, should not be pre¬ 
scribed with free acids or emulsin. 

Tannic acid and all substances containing it are incompatible with 
alkaloids and drugs containing them, with albumen and gelatin, and 
with most soluble metallic salts used in medicine. 

Iodine and iodides are incompatible with the alkaloids and the sub¬ 
stances containing them, as well as with most soluble metallic salts. 
The iodide of potassium* should always be prescribed alone, or only in 
combination with corrosive sublimate (with which it forms a double 
salt), or with iodine itself. 

Tinctures and other alcoholic preparations containing resin precipitate 
the latter when water is added. 

Nitrate of silver should always be prescribed alone, or in combina¬ 
tion with opium or extract of hyoscyamus only. Most vegetable extracts 
decompose it, and with creasote it is said to make an explosive compound. 

Corrosive sublimate is incompatible with almost everything, and 
should be given in simple syrup: even the compound syrup of sarsa¬ 
parilla is said to decompose it. 

Syrup of squill, containing acetic acid,is incompatible with carbonate 
of ammonium, but not with the chloride. 

Acetate and subacetate of lead are incompatible with almost every¬ 
thing, but are nevertheless frequently used in lotion with opium, the 
insoluble compound formed being therapeutically active. 

Vegetable inf usions are generally incompatible with metallic salts. 

Classification.— In every treatise on therapeutics some method of 
arranging the individual drugs is necessary. In earlier editions of this 
work I stated that no satisfactory classification of drugs seemed possi¬ 
ble with the then existent knowledge of the subject. Our acquaintance 
with therapeutic agents and their action upon the organism has enor¬ 
mously increased in the last two decades, and it has appeared to me 
that at present we can approach much more closely to a really scientific 
arrangement than was before possible. I have, therefore, arranged the 
book in accordance with the scheme directly hereafter set forth. Some 
of the families as here defined are not thoroughly natural, but most of 
the groups have much of unity in themselves, and of propriety in their 
relations. Thus, antispasmodics are little better than a heap of incon¬ 
gruities, but delirifacients are singularly united together and opposed 
to somnifacients, while antiperiodics, perhaps, ought to be merged in the 
alteratives, with which through arsenic they are closely related. 


* Death has resulted from a prescription containing strychnine and iodide of potassium, all 
the alkaloid being taken at the last dose. 



112 


PRELIMINARY CONSIDERATIONS. 


Division I. —Systemic Remedies, substances which act on the 
solid or fluid tissues of the body. 

Division II. —Extraneous Remedies, substances which are em¬ 
ployed to act on secretions, excretions, or other liquid or solid bodies 
which are not human tissues. 

SYSTEMIC REMEDIES. 

Class I. —General Remedies, drugs which affect the tissues of 
the body generally or such organized systems as reach all portions of 
the body. 

Order I. — Nervines , drugs which affect the nervous system. 

Order II.— Cardiants, drugs which affect the circulation. 

Order III. — Nutriants, drugs which affect the nutritive movements • 
of the body. 

NERVINES. 

A. Medicines which act upon the cerebrum. 

B. Medicines which act on the lower or nervo-muscular apparatus. 

A. 

Family I.— Antispasmodies, feeble cerebral stimulants which are em¬ 
ployed for the relief of minor spasms and other nervous symptoms, the 
result of insufficient nerve-power. 

Family II. — Anaesthetics , drugs which are used for the production 
of amesthesia. 

Family III. — Somnifacients , drugs which when in sufficient doses 
produce deep sleep without delirium. 

Family IV. — Delirifacients, drugs which when in sufficient doses 
produce delirium, followed by stupor. 

B. 

Family V. — Excito-motors , drugs which produce violent tetanic 
spasms. 

Family VI.— Depresso-motors, drugs which cause paralysis. 

CARDIANTS. 

Family I. — Cardiac Stimulants , drugs which increase the arterial 
pressure. 

Family II. — Cardiac Depressants , drugs which lower the arterial 
pressure. 

NUTRIANTS. 

Family I. — Astringents, drugs which call into exercise the vital func¬ 
tion of contractility. 

Family II. — Tonics , drugs which so influence nutrition as to increase 
the vital power. 




PRELIMINARY CONSIDERATIONS. 113 

Family III. — Alteratives , drugs which so modify nutrition as to 
overcome certain chronic pathological processes. 

Family IV.— Antiperiodics , drugs which so modify nutrition as to 
overcome the effects of malarial poisoning. 

Family V.— Antipyretics, drugs which so modify nutrition as to 
overcome febrile movements. 

Class II. —Local Remedies, drugs which affect one organ or ap¬ 
paratus more or less isolated from the remainder of the body. 

Family I.— Stomachics* 

“ II.— Emetics. 

“ III.— Cathartics. 

“ IV.— Diuretics. 

“ Y.— Diaphoretics. 

“ YI.— Expectorants. 

“ YII.— Emmenagogues. 

“ YIII.— Oxytocics. 

“ IX.— Sialagogues. 

“ X.— Errhines. 

“ XI.— Epispastics. 

“ XII.— Rubefacients. 

“ XIII. —Eschar otics. 

“ XIY.— Demulcents. 

“ XY.— Emollients. 

“ XYI.— Protectives. 

EXTRANEOUS REMEDIES. 

Family I.— Antacids. 

“ II.— Anthelmintics. 

“ III.— Digestants. 

“ IY.— Absorbents. 

“ Y.— Disinfectants. 


* The definitions are not given in these families, as they are old and well known and 
their names show the reader to what organs each applies. It should be stated, however, that 
the family stomachics contains drugs which are used simply as stimulants to the gastro¬ 
intestinal tract, including, therefore, Simple Bitters, so called, and Aromatics. 


8 



DIVISION I—SYSTEMIC REMEDIES. 


CLASS I—GENERAL REMEDIES. 

ORDER I.-NERVINES. 


FAMILY I.—ANTISPASMODICS. 

Under the name of Antispasmodics are grouped in this treatise a 
number of medicines generally of very feeble powers, but of frequent 
use. In certain conditions of the nervous system—conditions associated 
with weakness rather than with simple depression—the nerve-centres 
appear to be more susceptible than is normal to external impressions, 
as well as to those impulses which originate in the cerebral centres 
themselves and are connected with the emotions. As a result of this 
state, various symptoms arise, of trifling import, but often apparently 
severe, and always annoying. Such symptoms, in their mildest form, 
constitute the state of unrest known as nervousness; in their severer 
type they may rise in intensity up to the wildest convulsion of hysteria. 
It is in this class of affections that the so-called antispasmodics are 
useful. As the condition which they relieve is always associated with 
weakness, they are often spoken of as “ nerve-stimulants.” In regard 
to most of them there is but little evidence of their increasing power 
or functional activity when administered to healthy individuals. Some 
of them act very slightly upon the circulation when given in very 
large doses, and a few when administered as freely as possible induce 
slight cerebral symptoms, such as vertigo; but, except camphor and 
Hoffman’s Anodyne, none are capable of producing serious poison¬ 
ing. As any theory of the method in which the hysterical convulsion 
originates—of its immediate causes and the mechanism of its produc¬ 
tion—would, with our present knowledge, be at best but an ingenious 
speculation, the safest plan in regard to the action of drugs belonging 
to the class now under consideration is to accept the teachings of 
clinical experience as to facts, and to avoid theorizing as to the way in 
which the results are brought about. 

114 



A NTISPA SHOD ICS. 


115 


MOSCHUS—MUSK. U.S. 

A highly odorous, unctuous substance, obtained from the glands 
situated just in front of the preputial orifice of the Moschus moschif- 
erus, or musk-deer of Thibet. The genuine musk-sac is to be distin¬ 
guished from imitations of it by the hairs being arranged concentri¬ 
cally around a minute orifice. As it occurs in commerce, musk is very 
greatly adulterated. 

Physiological Action. —Musk appears to act upon the nervous 
system simply as a mild stimulant and antispasmodic. Jdrg and Sun- 
delin have experimented with it upon healthy men with somewhat 
contradictory results. According to the first-named observer, twenty 
grains of it induce exhilaration without lassitude, but, according to the 
latter authority, may cause giddiness, drowsiness, and lassitude. Both 
observers noted a slight increase in the frequency of the pulse. It seems 
to me evident that the action of musk upon the healthy organism is 
a very feeble and uncertain one. Yet there is considerable clinical 
evidence that when the nervous system is exhausted it is of service in 
calming restlessness and equalizing the disturbed balance of nervous 
power. 

Therapeutics. —Musk is at present very little used, but it is strongly 
recommended by some of the older writers in various spasmodic affec¬ 
tions, especially in hysterical convulsions. In hiccough it has been con¬ 
sidered a specific. In my experience, in the crisis of low fevers when 
the symptoms of nervous exhaustion are extreme and threaten death, 
musk is a very valuable remedy. Thus, in advanced typhoid fever a 
condition sometimes develops in which the pulse is exceedingly feeble, 
and the temperature has a tendency to rise to a great height, but 
yields almost immediately to the use of cold, only, however, to re¬ 
mount as soon as the cold is withdrawn. I have seen musk at such 
time control the temperature, steady the pulse, and apparently save 
life. In other cases of advanced fevers the powers of the system 
entirely give out, and the patient passes into a condition of collapse, 
with subnormal temperature, and mayhap coma-vigil: this state I 
have also seen relieved by musk. Many years ago Trousseau recom¬ 
mended musk very highly in the ataxic pneumonia of drunkards. In 
all cases of adynamic pneumonia with wild or muttering delirium musk 
is a very useful remedy. From ten to fifteen grains of musk (the best 
attainable) must be given at a dose, preferably by rectal injection, sus¬ 
pended in mucilage. The effect of the single dose lasts about six hours. 
The dose of the Tincture of Musk (Tinctura Moschi, —1 to 10, U.S.) is 
from one to two fluidrachms. 

Castoreum— Castor. —The preputial follicles of the beaver are pyri¬ 
form sacs, occurring in pairs, and containing an unctuous material,— 
the castor. This is a substance allied to musk in its physical properties, 


116 


GENERAL REMEDIES. 


and apparently also in its medicinal qualities. It is certainly less 
efficient, however, than musk, and Mr. Alexander ( Pereira's Materia 
Medica, American edition, 1866, p. 949) is said to have taken a quarter 
of an ounce of it without having experienced any effect. It is em¬ 
ployed in the same affections as musk, in doses of fifteen to sixty grains, 
suspended in mucilage. The tincture of the U. S. P. 1870 was stronger 
in alcohol than in castor. 

VALERIANA—VALERIAN. U.S. 

The root of the Valeriana officinalis, an herbaceous perennial of 
Great Britain. It consists of a short, yellowish-white rhizome, with 
numerous fibrous roots, of a bitter taste and peculiar odor. The active 
principle of valerian appears to be the oil of valerian , which, according 
to Pierlot, consists of a mixture of valerian camphene, valerian cam¬ 
phor, valerianic acid, resin, and water. 

Physiological Properties.— Upon cats valerian has a very ex¬ 
traordinary effect, attracting them strongly, and greatly exciting their 
sexual passions. It is possible that this action is suggestive, due rather 
to the resemblance of the odor to that of the animals during sexual 
excitement, than to a direct action of the drug. Valerianic acid given 
to rabbits in large doses produces, at first, a slight acceleration of the 
pulse, which, with the respiration, afterwards becomes less frequent 
than normal, and at the same time lassitude and muscular weakness 
are developed. Enormous doses kill rabbits somewhat suddenly, or 
cause fatal gastro-enteritis. 

Upon man, large doses (5ii to 5i v ) are said to produce a feeling of 
warmth in the stomach, and sometimes nausea, vomiting, and colicky 
pains. The pulse is generally slightly quickened, and a sense of ex¬ 
hilaration is induced, accompanied, however, by formication in the 
hands and feet. Very large amounts cause a feeling of heaviness, and 
even of pain, in the head. 

Therapeutics. —Clinical experience has demonstrated the value of 
valerian as a means of relief for the milder forms of functional dis¬ 
turbance dependent upon a weak and over-excitable or an exhausted 
nervous system. In the state of unrest familiarly known as “ nervous- 
?iess ,” by soothing and quieting the patient, it will often indirectly 
procure sleep. 

In hysteria it has been the most frequently used of medicines, and 
its action is ofttimes most happy. 

It has also been employed, but with more doubtful advantage, in 
mania a potu, and in the delirium of adynamic fevers. In these cases it 
is almost invariably conjoined with more powerful remedies, and it is 
very difficult to decide how far it assists in procuring the beneficial 
result. 

Administration. —The best preparations of valerian are the fluid 
extract (fExtractum Valerianae Fluidum, U.S.), dose, one fluidrachm; 


ANTISPA SHOD ICS. 


117 


and the ammoniated tincture (Tinctura Valerianae Ammoniata —gii to 
Oj, U.S.), dose, one to three fluidrachms. The dose of the infusion is 
a wineglassful; that of the simple tincture ( Tinctura Valerianae —gii to 
Oj, U.S.) is one to three fluidrachms. 

Acidum Valerianicum. — Valerianic Acid is an oily, colorless liquid, 
of a caustic taste, and a strong odor, resembling, but differing from, 
that of valerian. It is made by the action of chromic acid upon amylic 
alcohol, by a somewhat complicated process, and is employed for the 
manufacture of Valerianate of Ammonium (Ammonii Valerianas, U.S.), 
a white salt occurring in quadrangular plates, which effloresce in a dry 
and deliquesce in a moist atmosphere, have the odor of valerianic acid 
and a sharp sweetish taste, and are very soluble in water and in alcohol. 

Therapeutics.— Dr. W. B. Parke ( Therap. Gaz., 1887, 167) in some 
experiments in the laboratory of the University of Pennsylvania found 
that the valerianate of ammonium produces in the frog convulsions 
followed by general paralysis, both the convulsions and the palsy being 
due to an action upon the spinal cord. Brought in contact in a con¬ 
centrated form with any portion of the nerve-tissue, the valerianate 
produced rapid death of the part. It is very uncertain how far these 
results were due to the ammonia, and how far to the valerianic acid. 
They throw no light upon the therapeutic action of the drug, which 
was originally introduced by M. Declat, of Paris, as a remedy for 
neuralgia. It has since been used very largely for nervous headache and 
in hysteria. It appears to be about equivalent to valerian, but, unless it 
be in nervous headaches, is less efficient. The dose of it is ten grains, 
which is generally administered in the form of an elixir. 

ASAFCETIDA—ASAFETIDA. U.S. 

An exudation obtained by incising the living root of the Ferula 
Harthex, an umbelliferous plant of Afghanistan. It occurs mostly in 
irregular opaque masses of a dull yellowish- or pinkish-brown, white 
when freshly broken, of a bitter acrid taste and a strong garlicky 
odor. Even this lump asafetida is largely composed of tears aggluti¬ 
nated together; sometimes these tears are distinct and separate, when 
they constitute the variety known as asafetida in tears. Asafetida is 
composed chiefly of gum and resin, but its properties are in great part 
due to the volatile oil, of which it contains from 3.5 to 4.5 per cent. 

Physiological Action.— When taken into the stomach, asafetida 
acts as a local stimulant and carminative, and on this account is in 
some parts of the East used as a condiment. The oil is without doubt 
absorbed. The evidence as to its action upon healthy men is both 
scanty and contradictory. Thus, while M. Pidoux took half an ounce 
in a single dose without perceptible effects other than to render his 
secretions horribly offensive for two days, Jorg and his disciples found 
that in twenty-grain doses it produced gastric uneasiness and pain with 


118 


GENERAL REMEDIES. 


alvine dejections, increased the pulse-frequency and animal warmth, 
quickened the respiration, and caused headache, giddiness, and erotic 
excitement. 

Therapeutics. —Clinical experience has abundantly proved that asa- 
fetida is one of the most efficient of the so-called antispasmodics, and 
may be given to fulfil the same indications as valerian in functional 
spasm , in hysteria , and in nervousness. It differs from valerian in hav¬ 
ing a much more decided action upon the mucous membranes. It is 
an excellent carminative, and in the form of injection is constantly used 
for the relief of tympanites. It also in small doses increases the appe¬ 
tite, and affords relief in dyspepsia , with flatulent colic and costiveness, 
of the aged or hysterical. As a stimulating expectorant and antispas- 
modic, it is useful in whooping-cough and in chronic bronchial catarrh. It 
is especially efficient in palliating the latter affection as occurring in 
old people, when the difficulty of breathing is paroxysmally increased 
by spasm of the bronchial tubes. In infantile convulsions and in severe 
infantile colic , asafetida enemata (f5ii to fgss of the milk) are exceed¬ 
ingly useful and harmless. 

Administration. —The Pills of Asafetida (Pdulce Asafcetidce, U.S.) 
each contain three grains: from two to four may be given at once. 

The dose of the mixture or milk of asafetida (Mistura Asafcetidce — 
5ii to Oj, U.S.) is half to one fluidounce; for injections, one to three 
fluidounces; that of the tincture (Tinctura Asafcetidce — 5ii to Oj, 
U.S.), half to one fluidrachm. The suppositories contain the equivalent 
of forty minims of the tincture. Emplastrum Asafcetidce , U.S., is used 
externally. 

CAMPHORA—CAMPHOR. U.S. 

Camphor is obtained in China, Japan, Cochin China, the Sunda 
Islands, etc., by boiling the comminuted wood of the root, stem, and 
branches of the Laurus Camphora, and skimming off the camphor as 
it rises to the surface of the water when cooled. This camphor is then 
partially purified by sublimation, and comes into commerce as crude 
camphor , which is in grains of a whitish or pinkish color, and is finally 
purified by sublimation with lime* 

Refined camphor (or, as it is commonly called, camphoi ') occurs in 
disks or hemispherical bowl-like translucent masses, of a fibrous or 
granular fracture. Its taste is hot and peculiar; its odor very strong 
and characteristic ; it is volatile, inflammable, tough, but readily pul¬ 
verized on the addition of a few drops of alcohol; melts at 347° F.; 
is soluble in one thousand parts of cold water,j- in one part of strong 


* A variety of camphor, as well as of camphor oil, yielded by the Dryobalanops Camphora, 
is very highly valued in the East, but does not reach this country. For a physiological study 
of it, by Paolo Pellacani, see Arch. Exper, Pathol, und Pharm., xvii. 376. 

-f- By rubbing the gum up with magnesia in water, the latter can be made to take up much 
more than one part in one thousand. 



ANTISPASMODICS. 


119 


alcohol, and still more soluble in chloroform; thrown upon water, a 
granule of camphor floats, and exhibits a rotatory movement. 

By slow sublimation at ordinary temperatures, camphor can be made 
to crystallize in handsome hexagonal tables. 

Physiological Action.— Locally applied, camphor is a decided irri¬ 
tant, although when it is taken into the mouth a sense of coolness after 
a time is experienced, due no doubt to the volatility of the drug : a pre¬ 
cisely analogous phenomenon occurs with some other volatile irritants, 
such as oil of peppermint* 

Great differences of opinion have prevailed in regard to the action 
of camphor upon man, and it is scarcely doubtful that it acts differ¬ 
ently upon different persons, or at least that doses which in some cause 
only exhilaration produce general depression in others. When a mod¬ 
erate dose (five to ten grains) of camphor is taken, a feeling of exhil¬ 
aration is usually induced, a sense of comfort and quietness, especially 
marked in those previously suffering from “ nervousnessthe pulse 
may be somewhat accelerated, although it is undoubtedly not mark¬ 
edly affected in the majority of cases, and Trousseau saw it fall after 
the ingestion of ten grains of the drug. After larger doses (twenty 
to thirty grains) the pulse is usually lowered in frequency, and giddi¬ 
ness, with a feeling of lassitude, is produced, preceded, it may be, by a 
short period of exhilarative excitement. After poisonous doses (thirty 
to sixty grains) the symptoms, which are tolerably uniform, are as 
follows : faintness, headache, vertigo, confusion of ideas, burning pain 
in the stomach, delirium, violent convulsions, insensibility, general 
paralysis; a pulse generally small, but sometimes accelerated and some¬ 
times lowered in number; a skin cool, pale or livid, generally be¬ 
dewed with sweat. Sudden unconsciousness, with or without convul¬ 
sions, has been in some instances the first manifestation of the action 
of the poison, and, of course, in any individual case many of the symp¬ 
toms detailed above may be wanting.f 

No death has occurred in the adult directly from camphor. A sickly 
infant was killed by ten grains, and a child two years old by an unknown 
amount of strong alcoholic solution (New York Med. Rec., March, 1887); 
a woman four months pregnant died during an abortion, produced by 
three drachms. 

Much contradictory evidence might be adduced as to the influence 
of camphor upon the genital organs. The truth evidently is that its 
action varies according to the dose and the idiosyncrasies of the patient. 
In the great majority of instances, I think, camphor in moderate doses 
has no decided influence upon the sexual system; at least I have seen 


* For the physiological action of camphor-cymol, see Arch./. Exper. Path, und Therap. 

1873, Bd. i. 

. f Cases, Edinburgh Med. Journal, May, 1873; The Clinic, March, 1873; Wiener Medi- 
zinische Prase, 1874, p. 258; Berlin. Klin. Wochens., Sept. 1873-74; Trans. Bond. Clin. Soc., 

1874, p. 27; London Lancet, 1876, ii. 71; Brit. Med. Journ., Feb. 1S75, also 1877, i. 607. 



120 


GENERAL REMEDIES. 


many hundred such doses taken and have never yet seen any aphro¬ 
disiac effect. In some persons, however, full therapeutic doses are said 
to cause sexual excitement. In regard to very large doses, the testi¬ 
mony is quite uniform that if they exert any action it is to lessen the 
erotic feelings. 

Camphor acts upon articulates as a violent poison; in birds, accord¬ 
ing to Menghini, it causes stupor or delirium with epileptiform seizures; 
in mammals it produces symptoms similar to those seen in man, such 
as vomiting, violent convulsions, coma, and death, apparently from 
asphyxia. The convulsions must be of cerebral origin, as, according to 
the experiments of C. Weidemann {Arch. f. Exper. Path, und Therap ., 
vi. 216) and of Hoffmann (quoted by Weidemann), they do not occur 
after section of the cord in portions of the body below the point of 
division. Whether they are the result of a direct action upon the 
cerebrum is not determined, but the other symptoms produced by cam¬ 
phor indicate that the drug has a decided influence upon that organ. 
In frogs, Weidemann found that the convulsions are masked by a 
general paralysis, chiefly due to a depressant action upon the motor 
nerves,—the spinal cord, however, also suffering in its functional activ¬ 
ity, the muscles escaping. The action of toxic doses of camphor upon 
the circulation is decided. In the poisoned frog the cardiac beats be¬ 
come slow and powerful, and, as Heubner found ( Arch.f . Exper. Path, und 
Therap. , v. 427) that the camphor was able to excite the heart when 
arrested by muscarin, it is probable that its action is upon the heart 
itself. The same investigator failed to get any rise of arterial pressure 
in rabbits; but in the more extended researches of Weidemann it was 
found that in the convulsive stage of camphor-poisoning there is a very 
marked rise of the arterial pressure, which is largely due to the con¬ 
vulsions and disturbance of breathing, as it is in a measure prevented 
by curarization and artificial respiration. Under these circumstances, 
however, sudden periodical elevations of the arterial pressure occur. 
The cause of this phenomenon is not obvious, as Weidemann affirms 
that it is prevented by section either of the cord or of the vagi. As, 
after section of the cord, toxic doses of camphor lessen the arterial 
pressure, it would seem probable that it is directly depressant to the 
heart. 

Camphor is undoubtedly very much changed in the organism ; the 
most important of its derivatives is campho-glycurie acid, discovered by 
Schmiedeberg and Meyer (Zeitschrift f. Physiol. Chem., 1881), which, by 
warming with muriatic or sulphuric acid, is changed into Campherol ,* 
a crystallizable substance soluble in ether and also in water. 

Therapeutics. —Camphor is very largely used internally as an anti- 
spasmodic, to quiet restlessness and “ nervousness .” It is also employed 
in certain painful affections seen in those persons who are especially 


* For a physiological study of campherol, see Archiv f. Exper. Path., xvii. 372. 



A NTISPA SMODICS. 


121 


liable to the condition of the nervous system just mentioned: thus, it 
is often useful in nervous headaches and dysmenorrhoea. Indeed, in the 
latter disease, either alone or combined with opium in bad cases, it is a 
most valuable drug, but must be given freely. In diarrhoea not depend¬ 
ent upon inflammation, in cholerine, and even to some extent in cholera , 
camphor is a very efficient remedy, allaying intestinal pain and spasm, 
and also checking intestinal secretion. It enters into a large propor¬ 
tion of the popular cholera-mixtures. In adynamic fevers it has been 
very greatly employed, but is of doubtful advantage : still, a good deal 
of testimony could be adduced in favor of its usefulness in sustaining 
the system in the low stages of the diseases; and in the nervous restless¬ 
ness occurring at such times it is often very soothing. In abnormal 
sexual excitement, and in chordee, large doses of camphor very often 
appear to act most happily. The drug has also been very frequently 
exhibited in various spasmodic affections, such as whooping-cough, epi¬ 
lepsy , and even puerperal and strychnic convulsions, but is, I believe, at 
present never so employed. In hysterical convulsions , as in other phe¬ 
nomena of the same origin, camphor is a useful antispasmodic. 

Externally, camphor is much used in liniments as a stimulant appli¬ 
cation for bruises, sprains, etc. 

Administration. —Large doses (ten to fifteen grains) of camphor 
are best administered in emulsion, because when given in this way, 
being very finely subdivided, they create as little irritation as possible, 
and are rapidly absorbed; smaller doses may be given in pill. As an 
antispasmodic, the Camphor Water {Aqua Camphorce — 1 to 125, U.S.) 
is usually preferred; its dose is half a fluidounce to two fluidounces, 
but, when a decided effect is desired, the Spirit of Camphor (Spiritus 
Camphorce —1 to 10, U.S.) is preferable; its dose is half a fluidrachm. 
For external use, the Linimentum Camphorce (camphor one part, olive 
oil six parts, U.S.) and the Linimentum Saponis, or Soap Liniment, U.S., 
—a mild liniment, very popular either by itself or as the basis of more 
stimulating preparations. 

Oleum Camphorje. — Oil of Camphor is the volatile oil of the Cam- 
phora officinarum. As it occurs in our market, it is a reddish or yellow¬ 
ish-brown liquid, having a strong odor of camphor, and a hot, cam- 
phoraceous taste. It contains camphor in solution, and is probably 
equivalent to it in physiological action, except that it is locally more 
stimulating, and therefore preferable in intestinal disorders. The dose 
is five to ten drops. 

Camphora Monobromata. U.S.— Monobromated Camphor, or Bro- 
mated Camphor. —With iodine and bromine camphor unites to form com¬ 
pounds. According to Laurent, bromcamphor occurs in red orthorhom¬ 
bic crystals. These when exposed to the air undergo rapid spontaneous 
decomposition, but by heating in a closed vessel are resolved into hy- 


122 


GENERAL REMEDIES. 


drobromic acid, and a compound in which one atom of hydrogen in the 
camphor has been replaced by bromine. This bromated camphor is a 
crystalline solid, or occurs in large acicular crystals several inches long. 

Our present knowledge of the physiological properties of bromated 
camphor rests upon the work of Bourneville (Le Progres Med., 1874; 
also Compt.-Rend., Aout, 1875), of Lawson (. Practitioner , 1874, 1875), 
of Pathault ( Bromure de Camphor, Paris, 1875), of Pickard Peters 
( Schmidt's Jahrb., Bd. ci. 126), and of Pellicani (Ibid.). In frogs there 
is progressive loss of reflex excitability and of voluntary movement 
(Peters), which, according to Pellicani, is due to paralysis of the motor 
nerves. Death is caused by arrest of respiration (Peters). In mam¬ 
mals it produces violent convulsions, muscular weakness passing almost 
into paralysis, reduction of temperature (after small doses preceded by 
a rise—Peters), great decrease in the rate of the respiration and of the 
pulse, with occasional periods of hurried respiration (Peters), profound 
sleep or stupor, and finally death. Bourneville states that the blood¬ 
vessels of the eyes and ears are diminished in calibre. Upon man the 
drug probably acts as upon other warm-blooded animals; in a case re¬ 
ported by M. Rosenthal (Schmidt's Jahrb., Bd. ci. 127), forty-five grains 
of it caused tremblings, marked slowing of the pulse, and coma of six 
hours’ duration. 

Therapeutics. —Bromated camphor was first introduced by Pro¬ 
fessor Deneffe (Presse Med. Beige, 1871) as a nervous sedative, and as an 
antispasmodic, especially in delirium tremens. It has not, however, sus¬ 
tained its first rapidly acquired reputation, and is little used. I have 
seen it do good in spermatorrhoea, and it may be tried in chordee, but 
especially in hysteria and allied convulsive disorders. It is taken with 
difficulty, and is apt to irritate the stomach. Bourneville proposes the 
following formula for hypodermic use: Bromated camphor, gr. xlv; Al¬ 
cohol, f3ix; Glycerin, f5vss; but Lawson states that bromated camphor 
is so pungent that it cannot be employed hypodermically. The dose of 
the drug is five to ten grains, given after meals in capsule or coated pill, 
and repeated as necessary. In Bourneville’s experiments twelve grains 
injected under the skin of a cat caused death in seventy-two hours. 

Carbolated Camphor. —When fifteen grains of carbolic acid dis¬ 
solved in an equal quantity of alcohol ai*e rubbed up with thirty-five 
and a half grains of camphor, an oily, pale-yellow liquid with a feeble 
odor of camphor results. This does not mix with water or glycerin, 
but does with almond and olive oil. It has been proposed by Dr. Soulez 
as a non-irritant, antiseptic dressing for wounds (see Amer. Journ. Med. 
Sci., July, 1877, or London Med. Record , May, 1877). 

SUCCINUM—AMBER. 

Amber is a fossil resin found on the southern coasts of the Baltic 
and in other portions of the world. It is not itself officinal or used in 


A NTISPA S MO DICS. 123 

medicine, but by destructive distillation yields an empyreumatic oil which 
is included in the Materia Medica list of the U. S. Pharmacopoeia. 

OLEUM SUCCINI—OIL OF AMBER. U.S. 

Oil of amber is an amber-colored liquid, of a hot taste, and a very 
strong, disagreeable odor. As kept in the shops it is said to be usually 
sophisticated. It is a powerful local irritant, and has been used as a 
rubefacient in chronic rheumatism and similar disorders. It is also an 
efficient antispasmodic, and as such is used in hysteria , in whooping-cough , 
and in infantile convulsions. In the bronchitis of infants, with severe 
nervous symptoms, as well as in the two affections last named, it is very 
useful as a counter-irritant and nerve-stimulant when diluted with from 
one to three parts of olive oil and freely applied over the spine. In 
obstinate hiccough , given by the stomach, it is probably, next to musk, 
the most efficient remedy. Dose, ten to twenty drops, given in emul¬ 
sion. One tablespoonful caused violent vomiting and diarrhoea, with 
marked fever and symptoms of general intoxication followed by re¬ 
covery notwithstanding the fact that the woman aborted ( Viertel- 
jahrsch. f. Gerichtl. Med ., xliii.). 

SPIRITUS ./ETHERIS COMPOSITUS—COMPOUND SPIRIT OF ETHER. 

U.S. 

Hoffmann's Anodyne consists of alcohol a pint, ether half a pint, and 
ethereal oil six fluidrachms. It is a colorless, inflammable liquid, of 
an aromatic, ethereal odor, and a burning, slightly sweetish taste. Its 
specific gravity is 0.815. Hoffmann’s anodyne is sometimes offered for 
sale without the ethereal oil. Forty drops of the genuine preparation 
will render a pint of water distinctly milky; but if no oil of wine be 
present, milkiness will not occur. Ethereal Oil (Oleum j. Ethereum , U.S.) 
is a transparent, nearly colorless, volatile liquid, of a peculiar aromatic 
odor, and a sharp, bitter taste. Its specific gravity is 0.91. It is heavy 
oil of wine , prepared by the action of an excess of sulphuric acid on 
alcohol, and diluted with an equal part of strong ether. 

Physiological and Therapeutic Action. —Dr. H. A. Hare, in studies 
made in the laboratory of the University of Pennsylvania, found that 
the heavy oil of wine produces, when in moderate dose, a rise in the pulse- 
rate and in the arterial pressure, followed, if the amount of the poison 
has been sufficient, by a very remarkable fall in the arterial pressure, 
and also in the pulse-rate. The rise in the arterial pressure did not occur 
when the spinal cord had been severed high up, and must, therefore, 
be in large part, if not altogether, due to a stimulant influence upon the 
vaso-motor centre. In the period of lowering of pressure the individual 
heart-beats were extremely full and strong, indicating that the fall of 
pressure is due to the widening out of the blood-paths by a vaso-motor 
paralysis. Dr. Hare believes that this paralysis is chiefly peripheral, 
because he found that the fall was not so great in the dog in which the 


124 


GENERAL REMEDIES. 


cord was intact as it was when the cord had been divided. The rapidity 
of the beat of the isolated frog’s heart was at first increased by the 
drug, but it was not positively determined how far the heavy oil of 
wine acts in small doses as a cardiac stimulant: that very large doses 
paralyze the heart by a direct action on the muscle, was indicated by 
the final diastolic arrest. Careful studies upon frogs by Dr. Hare failed 
to detect any indication of an action of the oil upon the spinal cord, 
nerves, or muscles. The toxic properties of the heavy oil of wine are 
very feeble: 30 cubic centimetres given by the mouth to a small dog 
weighing twelve pounds failed to produce marked symptoms. It is 
evident that the small quantity of the heavy oil of wine contained in 
Hoffmann’s anodyne can exert no very pronounced influence upon the 
human system. But it probably has a slight stimulant, calmative effect, 
since clinical experience indicates that Hoffmann’s anodyne is more per¬ 
sistent and powerful than an equivalent amount of ether. It is a very 
efficient carminative, and is also a useful antispasmodic in all the dis¬ 
orders for which such remedies are employed, especially when there 
is a tendency to failure of the circulation, as in valvular cardiac disease. 
The dose is one or two fluidrachms, repeated in half an hour or an hour, 
if required, and given in cold water. 

HUMULUS-HOPS. U.S. 

The strobiles of Humulus Lupulus, or the hop-vine, cultivated in 
northern and middle Europe and in the United States. Hops are soft, 
greenish cones, one or two inches in length, composed of thin, leaf-like, 
imbricated scales, having a hitter taste and a heavy narcotic odor. At 
the bases of the scales is a yellowish powder, officinal under the name 
of Lupulinum. Lupulin is in minute grains, and contains, according to 
Payen, 2 per cent, of volatile oil, 10.30 per cent, of bitter principle, and 
50 to 55 per cent, of resin. Volatile oil of hops is yellowish, and has a 
strong odor of the drug, and an acrid taste. The bitter principle has 
been obtained by Lermer in brilliant rhombic columns, of an acid re¬ 
action. 

Therapeutics. —Hops are a bitter tonic, and a very feeble narcotic, 
producing, when taken very freely, some heaviness, and perhaps sleep. 
They are especially useful as tonics in cases of nervous irritability re¬ 
quiring medicines of the class. In delirium tremens they are very largely 
used to quiet nervous irritability, to aid more powerful remedies in 
procuring sleep, and at the same time to strengthen digestion. In 
priapism , in irritation of the bladder , and in abnormal sexual excitement , 
hops have been exhibited with asserted benefit. They may be tried in 
large doses, but usually will fail. 

Externally, hops are employed in the form of poultices, and when 
fresh seem to aid the heat and moisture in allaying pain. 

Administration.— The dose of the tincture {Tinctura Humuli —1 to 
5, U.S.) is half a fluidounce to three fluidounces. Eor a decided narcotic 


ANTISPASMODICS. 


125 


effect the practitioner may use either the oleoresin of Lupulin ( Oleoresina 
Eupulince, U.S.), dose, ten minims to a fluidrachm, in capsules if desired, 
or the fluid extract (fExtractum Eupulince Fluidum , U.S.), dose, half a 
fluidrachm to two fluidrachms. 

A hop poultice is made by moistening with hot water the hops con¬ 
tained, alone or mixed with an equal part of Indian meal, in a gauze 
bag of the required size and shape. 

LACTUCARIUM. U.S. 

The concrete juice of the Lactuca sativa,* or garden lettuce, occurs 
in two forms in our markets. The English variety is in small irregular 
pieces about the size of a pea; the German, in masses about an inch in 
length and half an inch in thickness. The color varies from a dark 
reddish-brown to a light yellowish-brown. The odor is faintly narcotic, 
the taste bitter. It contains a bitter, crystallizable principle, Lactucin . 

Therapeutics. —Lactucarium is certainly a very feeble drug. Bou- 
chardat gave half an ounce to a dog, with merely negative results; 
and in a number of trials made with it some years since I was un¬ 
able to perceive that it exerted any influence. It has been asserted 
that it exerts a peculiar soothing, hypnotic influence, like to, but much 
less intense than, that of opium, and free from its disagreeable after¬ 
effects. It may be that the drug varies according to age, time and 
mode of preparation, etc. Lactucin has been experimented with by 
Fronmiiller, who found it proportionately less hypnotic than the crude 
drug ( Deutsche Klinik, 1865). The usually assigned dose of lactu¬ 
carium is thirty grains, that of the fluid extract fExtractum Lactucarii 
Fluidum, U.S.) half a fluidrachm. Much larger quantities may be 
given with little effect. 

CIMICIFUGA—BLACK SNA REBOOT. U.S. 

The root of Cimicifuga racemosa, an indigenous herbaceous plant, 
growing abundantly in rich, shady woods, attaining a height of six or 
seven feet, and readily distinguished by its very large multi-compound 
leaves and its long-branched spikes of whitish polyandrous flowers, 
naked when open. The root consists of a knotted head, with numerous 
fine, brittle rootlets; the odor is faint, and the taste bitterish, somewhat 
astringent and acrid. It has not yet been determined exactly upon 
what the activity of cimicifuga depends. Mr. Geo. H. Davis has found 
in it a volatile oil, which Professor Geo. B. Wood thinks is very prob¬ 
ably active, since the virtues of the drug deteriorate on keeping. 
There are also two resins in the root. 

Physiological Action.— Cimicifuga was introduced to the profes¬ 
sion by Dr. Young in 1831 fAmer. Journ. Med. Sci., vol. ix.), and Pro¬ 
fessor Chapman, in his Elements of Therapeutics , affirmed that in full 


* For a case of reputed poisoning by Lactuca virosa, see Schmidt’a Jahrb ., Bd. clxxi. p. 137. 





126 


GENERAL REMEDIES. 


doses it causes nausea, more or less general relaxation, vertigo, tremors, 
and decided reduction of the pulse; while in 1848 Dr. H. S. Davis 
(Trans. Amer. Med. Assoc., vol. i. p. 351) dwelt very strongly upon its 
sedative influence. There have been no cases of human poisoning by 
it. I have seen it, however, when given in large doses produce giddi¬ 
ness with intense headache and general prostration, evidences that it 
has some influence upon the cerebrum. It also occasionally vomits, 
but its emetic action is never violent, and is probably simply the re¬ 
sult of a gentle irritation of the stomach. Its effects upon the lower 
animals have been investigated by Dr. Randall Hutchinson (Therap. 
Graz., 1887, 731), who finds that in frogs it produces general and com¬ 
plete anaesthesia with loss of reflex activity, voluntary movement being 
preserved at a time when burning of the feet elicits no jiain or motion. 
As tying the artery of the leg so as to protect the limb from the direct 
action of the drug on the nerve and muscles did not influence the de¬ 
velopment of the anaesthesia, this symptom must be due to a paralysis 
of the sensory side of the spinal cord. Both motor nerves and muscles 
were found after death functionally active. When the cimicifuga was 
brought directly in contact either with the isolated frog’s heart or with 
the exposed heart still in situ , the movements became slow, and in a little 
while the muscle was entirely paralyzed. In mammals, cimicifuga pro¬ 
duced fall in the arterial pressure, with a slowing of the pulse, which 
was not prevented by previous section of the vagi, and finally diastolic 
arrest,—facts which prove that the drug is a direct depressant to the 
heart-muscle or its ganglia. Hutchinson further found that when the 
arterial pressure is low asphyxia produces no rise, so that it is probable 
that the vaso-motor centres are also paralyzed. The respirations are 
affected by cimicifuga, becoming slow, altered in rhythm, and suffering 
final arrest. 

Therapeutics. —Cimicifuga was originally proposed by Dr. Young 
as a remedy in chorea , and in the simple chorea of childhood its value 
is unquestionable. It must be given freely, and in most cases the con¬ 
sentaneous exhibition of iron and laxatives materially aids it. In acute 
inflammatory rheumatism cimicifuga has been highly recommended by 
Dr. Davis and other practitioners. I have seen it do good, but it is at 
present very rarely, if ever, used. In chronic bronchitis it is sometimes 
employed with asserted benefit, especially when the expectoration is 
free and hectic fever exists. 

Administration.— As cimicifuga deteriorates by keeping, the fresh 
drug should always be used. The powder (dose, twenty grains) is pre¬ 
ferred by some practitioners; but I have found the officinal fluid extract 
(Extractum Cimicifugce Fluidum , U.S.) very active in doses of from 
twenty minims to a fluidrachm. The dose of the tincture (Tinctura 
Cimicifugce —1 to 5, U.S.) is one to two fluidrachms. 


FAMILY II.—ANAESTHETICS. 


The term Ancesthetics is here employed as the name of a group of 
volatile substances, whose vapor has the power of producing loss of 
consciousness, preceded by or accompanied with loss of sensibility and 
diminished muscular action. The medical properties of these sub¬ 
stances are largely due to their volatility, by virtue of which they 
are very rapidly absorbed and almost as rapidly eliminated by the 
mucous membrane of the lungs. As a consequence of this, their 
action is easily controlled. That they are taken into the blood, and 
thereby reach all portions of the system, has been abundantly proved 
by recent investigations.* 

The action of the anaesthetics certainly is upon the nerve-centres. 
Thus, Bernard has shown (loc. cit .) that a ligature so placed as to cut 
off all circulation from the posterior part of the frog does not prevent 
the production of abolition of sensation, voluntary motion, and reflex 
action in the hind legs when an anaesthetic is injected into the anterior 
part of the body. 

Many of the theories which have been suggested to explain the 
production of anaesthesia are so groundless that it seems unnecessary 
to discuss them here. All that are worthy of consideration may, I 
think, be arranged in four groups, as follows: 1st, those which assert 
that the symptoms are produced by a partial arrest of oxidation; 2d, 
those which look upon anaesthesia as due to precedent physical changes 
in the blood; 3d, those which assert that anaesthesia, like sleep, is due 
to cerebral anaemia; 4th, those which teach that the various agents 
employed act directly upon the various organs and tissues concerned, 
—including in this group the theory of Bernard that anaesthesia is 
produced by a semi-coagulation of the nervous protoplasm.I 

As the theories of the last group are the most natural, the burden 
of proof rests upon the supporters of the other theories. All the 
proofs of the first two groups as yet brought forward amount to no 
more than as follows: that in asphyxia the symptoms are similar to 
those of anaesthesia; that in profound anaesthesia there is an evident 
lessening of oxidation; and that some anaesthetics probably produce 
changes in the blood. 

* See especially 0. Schrniedeberg, Inaugural Dissertation , Dorpat, 1867, Archiv d. Heil - 
kunde, viii., 1867 ; Claude Bernard, Lemons sur les Aneethesiquee, Paris, 1875. 

t For a study of the coagulation theory, see Centralblatt Med. Wiss., 1877, p. 609. 

127 




128 


GENERAL REMEDIES. 


The objections to regarding these facts as proving the truth of the 
theories alluded to are very grave. Thus, it is very well ascertained 
that the symptoms of asphyxia are only analogous to those of anaes¬ 
thesia, not identical,* and indeed that anaesthesia as caused by different 
agents offers different phenomena; also, there is no proof whatever that 
the lessened oxidation and the blood-changes which are believed to 
occur when anaesthetics are employed are causes of the nervous symp¬ 
toms, and not simply coincident phenomena. It must be insisted on ? 
therefore, that these theories have never been proved. Moreover, posi¬ 
tive proof of their incorrectness is not wanting. Thus, in regard to the 
theory of arrest of oxidation, there are substances, such as nitrite of 
amyl, which lessen oxidation, but are not anaesthetics ; and an excess of 
oxygen in the air does not lessen the rapidity with which anaesthesia is 
induced.^ The Anaesthetics Committee of the British Medical Association 
( Journ . Anat. and Phys., xiii. 224) also found that during chloroform-nar¬ 
cosis there was an actual increase in the elimination of carbonic acid. 
In regard to the blood-theories, Ludimar Hermann ( Reichert's Archiv , 
1866, p. 27) calls attention to the fact that the anaesthetics produce the 
same general symptoms in the infusoria, which have no red blood, as in 
mammals; and Lewisson| has shown that they influence the so-called 
“ salt frog,” which contains little or no blood, precisely as they do the 
normal frog, from which the conclusion is inevitable that they do not 
affect the frog by altering the nature of the blood or by inducing 
asphyxia. In regard to cerebral anaemia, it appears to be established 
that it occurs in sleep ; and Claude Bernard ( loc. cit., p. 122) has shown 
that during the period of excitement preceding anaesthesia there is 
cerebral congestion, but during the anaesthesia cerebral anaemia. Ces¬ 
sation of function normally results in anaemia of the organ, and the 
anaemia of sleep and anaesthesia is, in all probability, an effect, not a 
cause, of suspended cerebration. In the frog it has been abundantly 
proved that absolute anaemia of the nerve-centres does not suspend 
their functions, and that on the bloodless cerebrum chloroform exerts 
its usual influence. The only theory at all compatible with our present 
knowledge is that anaesthesia is in most cases due to a direct action 
of the agent inducing it upon the cortex cerebri and other nerve-centres. 

The action of the anaesthetic upon the nerve-structure is probably a 
purely vital one. But by no means all authorities acknowledge this. 
Many, if not all, of the anaesthetics have the power of dissolving the 
red corpuscles; and Ludimar Hermann ( Reichert's Archiv, 1866) has 
pointed out a possible connection between this and anaesthesia. He 
states that protagon, which constitutes the stroma of the red blood- 
disks, is an important constituent of the nerve-centres. As death 
would necessarily occur before the protagon could be dissolved out of 


* See Report of Chloroform Committee, Medico-Chirurg. Trans., vol. xlyiii. p. 329. 
f Ibid., p. 335. J See Chloral for further details. 



ANAESTHETICS. 


129 


the nerve-centres,— i.e., before it could be dissolved out of the red cor¬ 
puscles,—it is evident that no extensive destruction of the latter bodies 
can occur from the action of an anaesthetic and the patient survive. 
Bile-acids also dissolve protagon, and Hermann states that some ex¬ 
periments he has made seem to indicate that they have anaesthetic 
properties. Before, however, the ingenious theory of Hermann can 
be considered proved, further investigations must be made. The 
coagulation theory of Bernard rests almost solely upon the doubtful 
allegation that anaesthetics applied in sufficient concentration coagu¬ 
late albuminous substances, and appears to me such a pure assumption 
that its discussion at length is beyond the plan of the present work. 

In 1848 (. Archives Gen., 2e ser., t. xvi., 1848) Dumeril and Demar- 
quay showed that during anaesthesia there is a reduction of tempera¬ 
ture. This has been confirmed by Bouisson ( Traite theorique et 'pratique 
de la Methode anesthesique , Paris, 1850) and by Sulzynski ( Ueber die 
des Alkohols, etc., Inaug. Diss., Dorpat, 1865); and Scheinson (Archiv 
der Heilkunde, 1869) asserts that there is no increase in the giving 
out of heat by the body during anaesthesia, and consequently that 
the anaesthetics lessen the production of animal heat, no doubt, like 
alcohol, by checking tissue-metamorphosis. Albumen is not rarely 
to be found in the urine after anaesthesia, and G. Guerrin states that 
after anaesthesia by nitrous oxide on the addition of nitric acid an 
intense rose coloration appears. (These, Ho. 299, Lyons, 1885.) 

The action of anaesthetics may be modified by the injection of nar¬ 
cotics. Morphine given hypodermically about half an hour before the 
exhibition of the anaesthetic is said to have a decided effect in pro¬ 
longing the anaesthesia. Chloral administered shortly before etheriza¬ 
tion certainly causes the first stages of the latter to be much quieter 
than usual, and also prolongs the narcosis.* 

The chief purposes for which anaesthetics are used are to relieve 
pain and to relax spasm . To meet the first indication they are em¬ 
ployed by surgeons especially; but they are also exceedingly valuable 
in cases of suffering from disease. It must be borne in mind that their 
action is very transitory and is accompanied by more or less disturbance 
of the general system, and that consequently they are to be employed 
only when the pain is exceedingly severe and transient. To relieve 
pain, anaesthetics are used with great propriety during child-hirth.-\ In 
natural labor it is not commonly necessary to produce complete anses- 


* Mr. Bon will has proposed rapid breathing as a means of producing slight anaesthesia in 
cases of minor surgery. The patient is required to breathe very rapidly for from three to five 
minutes, when a condition of partial loss of consciousness, probably dependent upon disturb¬ 
ance of the cerebral circulation, is induced. (See Phila. Med. Times, vi. 265.) 

f I see no reason for believing that anaesthesia of the mother seriously influences the 
child, and do not think much weight can be attached to the assertions of Dr. Hofmeier ( Ber¬ 
lin., Klin. Wochen8ch., 1883, xx. 230) that there is produced an increased elimination of 
nitrogen in the new-born babe. 


9 



130 


GENERAL REMEDIES. 


thesia. When the full effect of either ether or chloroform is induced, 
there is almost always a weakening, and very often an abolition, of the 
uterine contractions. The anaesthetic should be administered in such 
quantities as to relieve the pain without decidedly interfering with the 
muscular spasm. In certain cases this can be done, in others it is im¬ 
practicable. I have obtained very advantageous results in some cases 
by suspending the pains for about half an hour by means of ether, 
and then entirely withdrawing the anaesthetic. By this treatment the 
weak, painful, ineffectual efforts of a worn-out, nervous patient may 
often be converted into regular, successful pains. I think that the 
risk of post-partum hemorrhage is materially increased by anaesthetics, 
and therefore habitually give after their use two drachms of the fluid 
extract of ergot, as soon as the perineum is well distended by the 
child’s head. Anaesthetics are frequently used in surgery for the pur¬ 
pose of relaxing spasm, as in cases of dislocation , hernia , etc. In medi¬ 
cine, they have been employed in various forms of convulsions , and are 
especially valuable in severe hysterical convulsions , in puerperal eclampsia, 
and in spinal convulsions; in epilepsy they are very rarely called for; 
in infantile convulsions they may be sparingly used when the convul¬ 
sion itself threatens life. In various spasms of the excretory ducts or 
canals, and especially during the passage of calculi, they act very 
favorably, both by relieving pain and by producing relaxation. In 
asthma, and in spasmodic stricture of the oesophagus, as in all other 
cases of oft-repeated spasm, they should be administered only to meet 
temporary indications, as their habitual use is deleterious. 

The question as to the propriety of the administration of anaesthetics 
to persons suffering from organic disease is of the gravest importance, 
and in individual cases must often be answered with much hesitation. 
By some practitioners heart-disease is thought to be a positive contra¬ 
indication to anaesthetic agents; when, however, the organic disease does 
not produce any obvious functional derangement of the heart, and when 
the heart-muscle is in a fair condition of health, ether may be used to 
the point of anaesthesia, provided the circumstances of the case are such 
as to justify the surgeon’s taking a little risk. When, however, it is 
possible to avoid the anaesthetic by the use of cocaine or other device, 
this should be done. It must be remembered that pain or great emo¬ 
tional excitement may arrest at once the movement of a diseased heart. 
The shock and nerve-strain which attend a major surgical operation 
without anaesthetics would probably endanger cardiac arrest more than 
would the anaesthetic used to avoid them. When in cardiac disease 
anaesthesia is to be induced, nitrous oxide or ether should be employed. 
It seems probable, from our present experience, that of these two agents 
the nitrous oxide is attended with the less danger; and when prolonged 
anaesthesia is desirable it is probably best to produce the first loss of 
sensibility with nitrous oxide and then to maintain the unconsciousness 
by means of ether. 


ANESTHETICS. 


131 


It appears from the recorded accidents of anaesthesia that the ex¬ 
istence of brain-tumors or of other organic brain-disease is of more 
importance as contra-indicating the use of anaesthetics than is disease 
of the heart itself. When the brain-arteries are believed to be athero¬ 
matous, although no positive signs of organic brain-disease are present, 
anaesthesia should be induced by the surgeon with the greatest reluc¬ 
tance. Indeed, in cases of general atheroma ether must be administered 
with caution, on account of the marked tendency which it has to in¬ 
crease the blood-pressure. In such a case in the practice of Professor 
Agnew, of Philadelphia, rupture of a cerebral vessel and immediate 
death from apoplexy occurred. Dr. Moxon (. Lancet ., 1886, vol. i.) re¬ 
ports a case in which he believes (probably incorrectly) that thrombus 
formed in the coronary artery during insensibility from ether. 

Attention has recently been called ( New York Med. Record , vol. 
xxxi. p. 199) to the danger which attends the use of ether in Bright’s 
disease. Both Dr. Emmet and Dr. Millard report cases in which col¬ 
lapse with uraemic poisoning rapidly followed the administration of the 
anaesthetic. The clinical evidence which I have been able to gather 
together indicates that in patients suffering from renal disease chlo¬ 
roform is preferable to ether unless the heart-muscle has undergone 
secondary degeneration. This is probably because the amount of chlo¬ 
roform required to produce anaesthesia is so much smaller than that of 
ether that less strain is thrown upon the excreting organs for its elimi¬ 
nation. 

NITROGEN MONOXIDE—NITROUS OXIDE. (NO—N 2 0.) 

Nitrous oxide is a colorless, almost inodorous gas, of a sweetish taste. 
It is a very active supporter of combustion. Water absorbs nearly its 
own bulk of it. It is made by the distillation of the nitrate of ammo¬ 
nium, which resolves itself into the gas and water. Thus, NO,NH 4 =: 
N 2 0-f 2H 2 0. The wood-cut on the following page represents the best 
apparatus,* and the rules appended thereto embody all the necessary 
instructions for the production of the gas. As they are very concise, 
they should be followed to the letter. 

The various effects of increasing heat upon nitrate of ammonium 
are as follows: at 226° F. it fuses perfectly; at 302° F. it emits white 
fumes, condensing in drops; at 347° F. it effervesces slightly; at 356° 
F. it boils without decomposition; at 437° F. it effervesces rapidly; at 
460° F. it begins to evolve gas; at 482° F. it evolves gas in abundance; 
above 500° F. nitric oxide is given off. 

To determine the temperature, thermometers have been prepared 
which may be passed through the cork and into the retort, marking 
the following degrees: 226°, 356°, 460°, 482°, 500° F. 

To obtain the largest amount of gas, the nitrate should first be melted 

* This apparatus is furnished by the S. S. White Dental Manufacturing Company, of 
Philadelphia. 



132 


GENERAL REMEDIES. 


in the retort at a temperature just sufficient (226° to 250° F.). When 
melted, the heat may be at once carried up to the point of decomposi¬ 
tion, 460° F. If a gradually-increasing heat be used after the salt is 
melted, a portion of it will sublime unchanged until the temperature 
reaches 460° F. The heat should never be allowed to rise above 482° 



F., for beyond that noxious products are generated. After the gas has 
begun to come over briskly, the appearance of copious white fumes in 
the retort is an indication that the heat is too great. The nearer the 
heat can be kept at the point necessary to generate nitrous oxide, the 
purer will be the gas.—(Dr. Jas. W. White, Dental Materia Medica, 
Philadelphia, 1868.) 


















































































































































ANAESTHETICS. 


133 


After the gas has commenced to come over freely, it is generally 
best to lessen the amount of heat applied to the sand-bath. The gas 
should be allowed to stand over water for a few hours before using. It 
improves rather than deteriorates by age, and in a properly-constructed 
gasometer may be kept for many weeks, especially if the water between 
the holder and the receiver of the gasometer be covered with a thin film 
of oil, so as to prevent its yielding to the air the gas which it absorbs, 
until saturated. In manufacturing the gas, whenever the alkalinity 
of the potash solution in the jar No. 2 is lessened, all the washing-jars 
should be emptied and refilled. 


Place the holder in a level position, and fill it with water to within an inch or two of the 
lower edge of the taper rim. Open all the spigots, especially the one in the top of the re¬ 
ceiver, and gently sink it into the water; then close the spigot in the top of the receiver and 
that on the upper edge of the holder, and arrange the weights that are attached to the re¬ 
ceiver. Next put pure water into the jars,—No. 1 two-thirds full; Nos. 2 and 3 within one 
and a half inches of the top. Into jar No. 2 put a stick of caustic potash. 

Arrange the jars in line, and connect them by tubing as shown in the cut. The tube 
from the retort must connect with the long pipe of jar No. 1, and so on. Always be sure that 
the long pipe of each jar is next the retort. When properly arranged, a current of air blown 
into the tube intended to connect with the retort will cause the water to bubble in jars Nos. 
2 and 3, and, the spigot to which No. 3 is attached being open, the receiver will begin to rise. 

Put into the retort the quantity of ammonia intended to be used (1 pound will make 
about 30 gallons of gas). Connect the long pipe of the first jar to the retort by rubber tubing, 
so that the condensed steam may run into it. Now apply the heat gradually, and watch the 
process, being careful not to overheat the ammonia, which will be known by its violent boiling, 
instead of the gentle bubbling which indicates the proper temperature. Do not make gas 
faster than 30 gallons per hour. 

The heat should be shut olf before the ammonia is quite all decomposed, in order to avoid 
breaking the retort; and when the gas has ceased to come over, the retort should be discon¬ 
nected from the tubing, and the receiving spigot closed. 

It will be understood that the first jar is merely to receive the drip ; the use of the water 
is simply to keep the jar cool. Some recommend placing this jar into a bucket of cold water. 

The inhaling-tube is attached to the spigot at the top of the holder. 

The register indicates the number of gallons of gas in the holder, as well as the quantity 
inhaled. 

The water in jars Nos. 1 and 3 should be changed every time the gas is made; that in 
No. 2 about once a month, when fresh caustic potash should be added. The water in the 
holder will keep sweet a year or longer if gas is made frequently. 

Physiological Action.— Although nitrous oxide has been used 
enormously as an anaesthetic, and many papers have been written upon 
it, yet our knowledge of its physiological action is due to three or four 
observers. When pure nitrous oxide gas is inhaled for from half a 
minute to three minutes, insensibility is produced, preceded in many 
cases by decided evidences of excitement. Some persons under its 
influence will sink quietly away into unconsciousness, but others will 
become hilarious, erotic, or pugnacious, and be restrained only by force. 
During the stage of anaesthesia the patient presents the appearances of 
asphyxia. 

It is probable that the paralysis of function invades the different 
portions of the nervous system in the same order as does that caused 


134 


GENERAL REMEDIES. 


by ether; but we have no positive knowledge upon the subject. A 
single experiment of Dr. Amory (A r . Y. Med. Journ., Aug. 1870) indi¬ 
cates that upon the conducting power of the motor nerves nitrous 
oxide exerts very little or no influence. Dr. Amory, by means of a 
cerebrometer set into the skull of the dog, found that during the period 
of unconsciousness the cerebral pulsations are very decidedly lessened, 
and finally abolished, although the cerebral pressure is increased. This 
would seem to prove that the capillary cerebral circulation is checked 
and finally arrested, but that the amount of blood in the cerebrum is 
not lessened. 

It is well established that the gas is not capable of yielding its 
oxygen so as to support life. A taper will burn in it, it is true, but the 
decomposition of the nitrous oxide is due to the high heat, and at the 
temperature of the body it is a stable compound. MM. Jolyet and T. 
Blanche have found ( Archives de Physiologie, July, 1873) that seeds will 
not germinate in it, and that animals (frogs, sparrows, guinea-pigs, rab¬ 
bits) live no longer in an atmosphere of pure nitrous oxide than in one 
of nitrogen. Even Dr. Colton, who maintains the absurdity that nitrous 
oxide produces hyperoxygenation of the blood, states ( The Physiological 
Action of Nitrous Oxide Gas , Philadelphia, 1871) that in an atmosphere 
of the gas a mouse will live only from thirty to sixty seconds, a pigeon 
from one to two minutes, a kitten from one to two minutes, a frog from 
thirty to sixty minutes,—all dying of asphyxia. 

The French observers above named affirm that nitrous oxide has no 
effect upon the system,—that the phenomena induced are simply due 
to deprivation of oxygen. The series of facts which they have experi¬ 
mentally proved, and upon which their conclusions are based, are : 
1. An animal lives no longer in nitrous oxide than in nitrogen; 2. 
Anaesthesia occurs at the time that the blood of an animal becomes 
black; 3. Animals breathing an air containing sixty to eighty per cent, 
of nitrous oxide and twenty to forty per cent, of oxygen are unaf¬ 
fected ; 4. The analysis of the blood of two dogs yielded the following 
results: 

No. 1. Conscious. No. 2. Unconscious. 


Carbonic acid 
Nitrous oxide 
Oxygen . . 


. 46 per cent. 
. 29 per cent. 
. 19.7 per cent. 


Carbonic acid 
Nitrous oxide 
Oxygen . . 


. 36.6 per cent. 
. 34.6 per cent. 
. 3.3 per cent. 


and other analyses showed that the coma was not developed until 
the oxygen in the blood was reduced to three or four per cent.* It is 
evident that if the above analyses are, as from their reports they appear 
to be, reliable, the anaesthesia is not due to the presence of carbonic 
acid in the liquor sanguinis, since nearly ten per cent, more of that gas 


* These results are closely akin to those obtained by GrShant, who found that in animals 
narcotized with a mixture of carbonic acid and air, the gas of the blood contained 95.4 per 
cent, of carbonic acid ( Compt.-Rend. Soc. Biolog., 1887). 




ANESTHETICS. 


135 


was present in the blood of the conscious (No. 1) than in that of the 
unconscious dog (No. 2), and also that it is more rational to believe the 
decrease in the oxygen, rather than the slight increase in the amount 
of the nitrous oxide, made the difference between consciousness and 
unconsciousness. 

In this connection the very careful experiments of Dr. Amory are 
most interesting. He found that during nitrous oxide narcosis the 
amount of carbonic acid exhaled from the lungs is only two-thirds of 
that eliminated before the inhalation, and that immediately after the 
recovery of consciousness less than one-third the normal amount of 
carbonic acid is given off. 

This certainly is corroborative of the conclusions of the French 
observers, which have also received confirmation from the experiments 
of Mr. Elihu Thomson ( Phila. Med. Times , November 15, 1873), who 
found that animals in an atmosphere of hydrogen and nitrogen, and 
also in vacuo, suffered symptoms precisely similar to those caused by 
the inhalation of pure nitrous oxide; also, that in man the inhalation 
of pure nitrogen causes the symptoms of nitrous oxide narcosis, except 
that the sense of exhilaration is absent; finally, that nitrogen, hydro¬ 
gen, and nitrous oxide, as well as a vacuum, are rendered capable of 
supporting life by the introduction of a proportion of oxygen approach¬ 
ing that existing in common air. Dr. C. A. MacMunn ( The Spectro¬ 
scope in Medicine , London, 1880, pp. 73-75) finds that when an animal 
is killed by nitrous oxide the arterial blood gives only spectrum lines of 
reduced haemoglobin, while after chloroform those of oxyhsemoglobin 
are very apparent. 

As long ago as 1858, Dr. Ozanam, in a communication to the French 
Academy, stated that he had found in rabbits a mixture of carbonic 
acid and air to be a safe anaesthetic, and that he had used it success¬ 
fully in the human being. M. Grehant ( Compt.-Eend. Soc. Biol., 1887), 
following after the experiments of Paul Bert, found that a mixture 
of oxygen, air, and carbonic acid, so made as to contain 50 parts of air 
to 100 parts of carbonic acid and 20.8 parts of oxygen, will produce in 
the rabbit in two minutes a complete anesthesia which may be main¬ 
tained for hours, and which disappears in the course of two or three 
minutes if the animal be allowed to breathe air. 

The evidence so far cited would seem to prove that nitrous oxide 
produces anesthesia by causing asphyxia; but the phenomena of me¬ 
chanical asphyxia are asserted to be different from those caused by the 
gas. In the experiments of Krishaber (Lyman, Artificial Anaesthesia , 
New York, 1881, p. 315) the cii*culation was found to be very differ¬ 
ently affected by mechanical asphyxia and by the inhalation of nitrous 
oxide. Professor Paul Bert, of Paris, believing that the production or 
non-production of anaesthesia by nitrous oxide depends upon its tension 
in the blood, devised an apparatus by means of which the patient could 
inhale nitrous oxide gas, mixed with an equal amount of oxygen, under 


136 


GENERAL REMEDIES. 


a pressure of at least two atmospheres. The result is said to be very 
satisfactory, and the method to be at present extensively used in Paris. 
The objections to it are the expensiveness and cumbrousness of the 
apparatus. It is plain that the manner in which nitrous oxide acts 
cannot as yet be considered as positively determined, and that the 
subject still offers a good field for research. 

Therapeutics. —As an amesthetic, nitrous oxide is chiefly valuable 
when short, minor operations are to be performed. The rapidity with 
which insensibility is induced, and with which it disappears, combines 
with the general absence of after-effects to enhance the popularity of 
the gas. When, however, an operation requiring some little time for 
its performance is intended, ether is far preferable. Nitrous oxide has 
been administered to many thousands of persons, and there have been 
only four deaths attributable to it with any plausibility. In one of 
these ( Dental Cosmos , editorial, June, 1872) it is doubtful whether the 
gas had anything to do with the fatal result, or, indeed, whether it was 
really administered. In the second case (Brit. Journ. Dent. Sci., Feb¬ 
ruary, 1873), death from asphyxia, apparently induced by nitrous oxide, 
occurred in a healthy man. In the third, death is asserted to have 
been produced by syncope (Brit. Med. Journ., 1877, i. 460). For the 
fourth case, see Ibid., 1883, ii. 729. The opinion of Dr. Cartwright 
(Lancet, 1876, 689) and of Dr. W. Ottley (Ibid., 1883, i. 95), that in 
case of heart-disease permanent increase of the cardiac weakness is 
caused by nitrous gas inhalation, is certainly not established. 

Nitrous oxide is best administered from an india-rubber bag, which 
should contain at least eight gallons. The mouthqfiece should always 
be made with two valves, so that the expired gas will be thrown out 
into the air, and not back into the bag. 

Dr. Lafont (La France Med., vol. i., 1886) has called attention to the 
possible after-results produced by the asphyxia of nitrous oxide, and 
gives an account of a number of mishaps, among which may be men¬ 
tioned miscarriage, chlorosis, epileptic symptoms, and albuminuria. He 
especially warns against the possible production of diabetes mellitus, 
and reports a case in which sugar appeared in the urine twice in the 
same patient after the use of the gas. He also found, in an experiment 
on himself, sugar in large quantities after an experimental inhalation, 
and he was successful in producing glycosuria in the dog. I have seen 
one case of diabetes mellitus which ended fatally, and in which the 

* M. Lafont states that in the rabbit during the inhalation of nitrous oxide the respira¬ 
tions become more frequent and deeper, and then gradually subside to the moment of anaes¬ 
thesia without sudden arrest, the arterial pressure either not changing or gradually subsiding. 
In the dog the respiratory movements increase in frequency and fulness until the moment of 
anaesthesia, when respiration is panting; directly afterwards there is brusque arrest of respi¬ 
ration, which may prove fatal. During the inhalation there is an increase in the arterial 
pressure and of the frequency of the pulse until just before anesthesia, when the heart may 
beat more slowly, with extremely strong systoles. The heart may now suffer momentary 
arrest. The slow pulse with a high pressure persists a long time. 



ANAESTHETICS. 


137 


symptoms were first detected shortly after the inhalation of the gas, 
to which the patient, a physician, persistently attributed his disease. 

ETHER—ETHYL OXIDE. (C 4 H 5 O-C 4 H 10 O.) 

Ether is a colorless, very volatile liquid, obtained by the dehydration 
of alcohol by sulphuric acid. It is very inflammable, as is also its vapor, 
which is two and a half times heavier than air. It is freely soluble in 
alcohol, and is itself a powerful solvent. Its odor is strong and pecu¬ 
liar; its taste is hot. Its specific gravity, when pure, is 0.713, and its 
boiling-point 95° F. It is officinal in two forms. 

ASther—Ether. U.S.—This ether contains a large percentage of 
alcohol, and has a specific gravity of 0.750. When shaken with an 
equal bulk of water, it loses from one-fifth to one-fourth of its volume. 
A test-tube full of it held in the closed hand should begin to boil on the 
addition of a piece of broken glass. Any specimen which does not 
conform to these requirements probably contains an overplus of alcohol 
or of water. 

^Ether Fortior—Stronger Ether. U.S.—This ether should have 
a specific gravity of 0.728, should not lose more than one-eighth of its 
volume when shaken with an equal bulk of water, and in a test-tube 
held in the closed hand should boil vigorously on the addition of broken 
glass. 

Physiological Action.— The first effects of ether when inhaled are 
burning in the fauces and a feeling of strangulation, both due to the 
local impression of the irritant vapor. The primary indications of its sys¬ 
temic action are a sense of exhilaration and a lightness in the head, asso¬ 
ciated with a roaring or buzzing in the ears. These are soon succeeded 
by a feeling of the immediate surroundings being afar off, which soon 
fades into semi-unconsciousness, with visions and illusions. These are 
of various characters, and are often accompanied by a species of de¬ 
lirium. Some patients weep, others laugh; some shout, some pray, 
some rave, and some become exceedingly pugnacious. In rare in¬ 
stances the dreams become erotic; and cases are on record in which 
there were distinct evidences of the occurrence of a complete venereal 
orgasm. In this stage the patient in most cases may be more or less 
perfectly aroused. There is rarely sufficient anaesthesia for practical 
purposes before the period of complete unconsciousness. 

The second stage of ether-narcosis may be considered to begin 
with the complete loss of consciousness. In most cases some degree 
of muscular rigidity is at first still present, but soon passes off, and the 
patient lies relaxed and quiet, with slow, regular, automatic respiration. 
The occurrence of stertorous respiration, due to a paresis of the mus¬ 
cles of the palate, shows that the stage of muscular paralysis is being 


138 


GENERAL REMEDIES. 


reached. It should, except in rare cases, be the signal for the imme¬ 
diate withdrawal of the anaesthetic. 

The face during etherization is reddish; marked pallor and lividity 
are respectively important indications of failure of the heart’s action 
and failure of respiration. The stage of excitement generally lasts 
only a few minutes, but in some cases is prolonged, and in nervous 
women may pass into a violent fit of hysterics, which soon yields, how¬ 
ever, to a persistent use of the anaesthetic. The pulse is quickened and 
increased in force by ether, aud it will often maintain itself during a 
prolonged narcosis. If the vapor of ether be taken in a concentrated 
form, there is usually in the beginning a momentary arrest of respira¬ 
tion, accompanied by a decided sense of suffocation, evidently the result 
of the irritant action of the vapor upon the upper air-passages. So 
soon as this has passed off, the respirations are usually accelerated as 
well as deepened; but as the stage of anaesthesia is reached they be¬ 
come slower, and, if the inhalation of the ether be persisted in, they 
grow not only more and more distant, but also more and more shallow, 
until they are gradually extinguished. The respiratory phenomena 
seem to be the same in the lower mammalia as in man. It was noticed 
by Kratschmer ( Sitzungb. Wiener Akad ., 1870, Abth. ii.) that in the 
rabbit ether, when inhaled through the nose, produces at first a mo¬ 
mentary arrest of respiration in expiration. He also found that sec¬ 
tion of the vagi did not prevent this arrest, but that section of the 
trigemini did; also that the arrest never occurred when the ether was 
given through a tracheal fistula. This would appear to show that the 
phenomenon was a reflex one, due to the irritation of the peripheral 
ends of the trigemini. Its importance is much increased by the con¬ 
sentaneous spasm of the glottis, noticed by Kratschmer. It is possible 
that some of the accidents happening early in human amesthesia are 
the result of such spasm. As stated by Dr. P. Knoll ( Sitzungb . Wiener 
Akad., Oct. 1876), the alterations of respiration are sometimes replaced 
by very irregular breathing. In either case, if the inhalation of ether 
be persisted in, the respirations, at first quickened, grow slower and 
slower, and less and less deep, until they are gradually extinguished. 
Dr. Knoll experimentally determined that these later respiratory 
changes are not interfered with by previous section of the vagi, that 
they follow the injection of the narcotic into the blood, and that they 
are not due to disturbances of circulation, or to a deprivation of the 
respiratory centres of their oxygen; and he logically concludes that 
they are produced by a direct action of the drug upon the centres, at 
first stimulant in its character, but subsequently depressant. 

According to Professor Eulenberg, in the beginning of anaesthesia 
produced either by ether or by chloroform, the knee-jerk in man is 
increased; but, while this increase soon disappears when chloroform is 
employed, with ether it endures even into the narcosis (Hoffmann und 
Schwalbe Jahresb., 1883, p. 117). 


ANESTHETICS. 


139 


Upon the lower animals ether acts as upon man, and it has been 
shown by Claude Bernard that the most primitive infusoria are suscep¬ 
tible to its influence (Le Progres Med., 1876, p. 77). 

As the functions of the cerebrum are affected before those of the 
other portions of the nervous system, it is very apparent that the brain 
is especially sensitive to the narcotic. Flourens ( Comptes-Pendus , vol. 
xxiv., 1847, pp. 161, 242, 253, 340) found that, at a certain stage of 
etherization, pricking of the anterior or motor nerve-roots caused 
motor disturbance, although the posterior or sensory portions of the 
spinal centres were completely insensible. After a more prolonged 
inhalation, the anterior or motor centres also failed to respond to 
mechanical irritation, although the functions of the medulla oblongata 
were regularly performed, and stimulation of its anterior centres gave 
rise to motor disturbance, and pricking of its sensory portions even 
caused manifestations of pain. When the inhalation of ether was 
maintained for a sufficient time, the sensory and finally the motor func¬ 
tions of the medulla oblongata were compromised, and death from 
paralysis of the respiratory centres ensued. 

Longet (. Archives Gen., 4e ser., tome xiii. p. 374) in part confirms 
and in part questions the results of Flourens. He states that he has 
found the sensory functions abolished very early, but has never failed 
in any stage of the narcosis to get a response from the anterior part 
of the cord. These apparently different results are simply due to the 
fact that, while Flourens used only mechanical stimuli, Longet em¬ 
ployed powerful galvanic currents. 

Flourens was substantially correct, and the order of the involvement 
of the nerve-centres in man and animals is—first the cerebrum, next 
the sensory centres of the cord, next the motor centres of the cord, 
next the sensory centres of the medulla oblongata, and finally the 
motor centres of the medulla oblongata. 

That ether is capable of impressing the nerves seems established by 
the experiments of Longet ( loc. cit., p. 382) and of Serres ( Archives 
Gen., 4e ser., tome xiii. p. 433). These observers found that the direct 
application of ether to a nerve produced a paralysis of the sensory 
fibres of that nerve; so that pinching the nerve below the point of 
application caused no pain, although voluntary movement was pre¬ 
served, and galvanization of the nerve-trunk above the point of appli¬ 
cation induced spasms in the tributary muscles : i.e., the power of con¬ 
ducting an impulse downwards was preserved, that of conducting it 
upwards was lost. By a longer application of the anaesthetic the 
function of the efferent as well as of the afferent fibres was abolished, 
temporarily at first, but, if the application were persisted in, perma¬ 
nently. Practically, however, inhaled ether has no influence upon the 
nerve-trunks, because the nerve-centres are so much more sensitive to 
its influence that their functional power is abolished before the nerves 
are affected. Indeed, Conly ( Soc. de Biologie , February 13, 1876) found 


140 


GENERAL REMEDIES. 


that in animals killed by ether, chloroform, or chloral the motor nerves 
and muscles preserve their function longer than in animals killed by 
sudden violence.* 

Upon the motor system of organic life ether certainly acts, but 
much less energetically than upon the voluntary system. Thus, after 
death from ether the vermicular movements of the intestine, although 
less active than normal, are very rarely, if ever, entirely absent. 

It has been shown by the English Chloroform Committee and other 
investigators that ether increases very markedly the arterial pressure, 
and that even in a prolonged ether-narcosis there is usually no material 
diminution of this pressure until manifest failure of respiration has 
taken place. The rise of the pressure is probably due to an increase 
of the power of the heart and to a stimulation of the vaso-motor 
nerves.f Sansom ( Chloroform , p. 92, Phila., 1866) states that the vessels 
of the frog’s web can be seen to contract during the inhalation of ether, 
and that this vaso-motor spasm is very permanent, and does not yield 
to paralysis and passive dilatation until the anaesthesia has almost 
deepened into death. Dr. Bowditch and Mr. Minot also found (Boston 
Med. and Surg. Journ., May, 1874) that the vaso-motor centres are at 
first stimulated and afterwards depressed. 

Injected, unless in too large amount, directly into the jugular vein 
of the mammal, or applied directly to the frog’s heart, ether does not 
seriously depress the heart. When artificial respiration is maintained, 
animals bear an enormous amount of this drug without cardiac failure. 
When death is produced by ether, the heart generally continues to pul¬ 
sate for a long time after the arrest of respiration. It is evident that 
ether is as little of a cardiac depressant as is alcohol. 

It is frequently asserted that ether when added to blood coagulates 
it. A. Schmidt, however, states that the coagulation is due to ozone 
which has been generated by the ether and is contained in it, since 
freshly-distilled ether does not coagulate albuminous substances. 

The researches of Wittich ( Schmidt's Jahrbucher, Bd. cxlii. p. 212) 
and A. Schmidt ( Virchow's Archiv , vol. xxix., 1864, p. 19) have shown 
that when ether is added to the blood of horses,J cats, or rats, the red 


* Dr. F. H. Hooper was, I believe, the first to note that stimulation of the recurrent 
laryngeal nerve causes a dilatation of the glottis in the thoroughly etherized dog, although 
in the normal animal it always produces a constriction. This remarkable observation has 
given rise to several investigations, the most recent and extended of which is that of Prof. H. P. 
Bowditch (Amer. Journ. Med. Sci., April, 18S7), to which the reader is referred for a full sum¬ 
mary and discussion of the matter. Dr. Bowditch corroborates the observation of Hooper, and 
also finds that during partial etherization weak irritation of the recurrent nerves causes dila¬ 
tation and strong irritation constriction of the glottis. As yet no satisfactory explanation of 
these curious phenomena has been offered. 

f I believe there is a paper “ On the Action of Ether on the Circulation” in the Deutsches 
Zeitschrift fur Chirurgie, 1874, Bd. iv.; but I have not had access to the volume. 

J Schmidt ( loc. cit., p. 23) says that sometimes crystallization fails in the blood of the 
horse. 



ANAESTHETICS. 


141 


corpuscles disappear in a very short time, and, as their stroma cannot 
be demonstrated by the aid of reagents, this disappearance is due to 
its solution. The haemoglobin thus set free is dissolved in the serum, 
but the presence of the ether soon causes it to crystallize. There is no 
proof that these changes occur to any extent when ether is inhaled; 
and the usual rapid recovery from the effects of the anaesthetic indicates 
that there is no profound alteration of the blood. 

An imperfect study by Harley of the effect of ether on the gases 
contained in drawn blood indicates that ether does not exert much in¬ 
fluence upon their proportional amounts. It is, however, quite possible 
that a more thorough investigation would give a different result. 

Therapeutics. —As an anaesthetic, ether does not act with the 
rapidity and pleasantness of chloroform, but it has the advantage of 
safety. So dangerous is chloroform, and so safe is ether, that there 
is no excuse for the use of the former agent under ordinary circum¬ 
stances.* * * § 

The reason of the safety of ether is that, unlike chloroform, it does 
not suddenly paralyze the normal heart.f It may kill by inducing 
asphyxia (cases, British Med. Journ., vol. ii., 1873; Chicago Med. Journ., 
1877, p. 410; Le Progres Med., 1877, p. 677 ; JY. Y. Med. Journ., xxiii., 
p. 179),| but it does so slowly, and in the great majority of cases after 
warnings which can be overlooked only through the most reckless care¬ 
lessness. Many of the inconveniences which attend the use of ether 
can be obviated. Thus, in order to prevent the nausea which often 
follows the anaesthesia, the patient should avoid eating for at least six 
hours before the inhalation, and should take from one to two ounces of 
brandy just before commencing the latter process. 

Unlike the vapor of chloroform, the vapor of ether should be adminis¬ 
tered in a concentrated form. When so inhaled, in most persons it will 
produce complete insensibility in from three to eight minutes, provided 
that no uncharged air be admitted during the time named.§ According 
to Dr. Snow, air at 80° F. saturated with ether contains seventy-one 
per cent, of the vapor. This point is probably never reached in the 


* Twenty-seven cases of sudden death from ether are collected by Dr. H. M. Lyman 
(Artificial Anaesthesia, New York, 1881). In most cases the respiratory centres were already 
enfeebled. Brain-tumors, obstructions of the bowels, cancerous tumors, and renal disease 
are more important contra-indications than cardiac disease. In disease of the heart ether 
is probably the safest of the anaesthetics; but when there is excessive exhaustion of the 
nervous system its use requires great caution. Sudden pulmonic oedema, outpouring of 
bronchial mucus, and fatal cerebral hemorrhage have occurred during, or directly after, the 
anassthesia. 

f For a case in which a fatty heart apparently suffered sudden arrest, see Brit. Med. Journ., 
1887, ii. 602. 

J See also Gaz. Hebdom., 1878, p. 583. 

§ Various inhalers have been invented for facilitating the usb of ether, but they are 
very rarely used. For information on these points, see N. Y. Med. Record, May 1, 1866, and 
N. Y. Med. Journ., April, 1871. The inhaler of Dr. Allis is probably of real service. See 
Phila. Med. Times, vol. iv. 



142 


GENERAL REMEDIES. 


practical use of ether, but the more nearly it is approached the more 
rapid will be the induction of anaesthesia. 

The ordinary method of the administration of ether in Philadelphia 
is as follows: 

Out of stiff paper a cone is made of such size and shape that its base 
will fit closely over the nose and mouth of the patient. In this cone 
a napkin, a small towel, or a conical, hollowed-out sponge is to be placed. 
About an ounce and a half of ether having been poured on the napkin, 
the cone is to be closely applied to the face of the patient, and kept 
there. If anaesthesia be not complete in four or five minutes, a second 
dose of ether should be put on the napkin, care being taken that the 4 
removal of the cone from the face is only momentary. When patients 
are fastidious and a few moments are of no importance, the gradual 
commencement of the inhalation is much more pleasant, as the first 
choking sensation is thereby to a great extent avoided. 

In using ether at night, its inflammable nature must not be forgotten. 

I have seen fire flash from a candle through some four or five feet of 
diffused vapor to the sponge. The light should always be above the 
patient, as the high specific gravity of the vapor of ether causes it to 
fall towards the floor. 

Administered by the mouth, ether has been used with advantage 
in various forms of colic , but is generally inferior to chloroform. When, 
however, as in some cases of retrocedent or internal gout , there is with 
the painful gastric and intestinal spasm a condition bordering on col¬ 
lapse, the stimulant properties of ether make it very valuable. 

In sudden sinking-spells, either from poison or from natural causes, 
ether, as a powerful and very quickly acting stimulant, is often indi¬ 
cated. In some cases of this description it may even be administered 
by inhalation. Of course, under these circumstances its influence 
should not be carried nearly to the point of producing anaesthesia. 

As an anthelmintic , ether has been used by MM. Bourdier and Lortet 
with success against the tape-worm. For this purpose, an ounce and a 
half may be administered at once, followed in two hours by a full dose 
of castor oil. 

In hysteria, neuralgia, nervous headache, and spasmodic neuroses, such 
as hiccough and asthma, ether is occasionally employed with benefit. 

When ether is swallowed, it produces a sense of strangulation and 
choking, which seriously interferes with its use. For this reason, it is 
best given in capsules, or in ice-cold water. Probably large doses are 
best administered by putting them, mixed with an equal amount of 
brandy, on finely-cracked ice before drinking. The dose is from one 
fluidrachm to half a fluidounce. 

Etherization by the rectum has been tried, but has been discarded 
on account of the severe irritation of the rectum and lower bowel 
which it causes, as well as because of the slowness of the production 
of insensibility. 


ANESTHETICS. 


143 


CHLOROFORMUM—CHLOROFORM. 

Methenyl Chloride—Terchloride of Formyl (C 2 HC1 s —CHC1,). 

This substance, which was discovered in 1831 by Mr. Samuel Guthrie, 
of Sackett’s Harbor, New York, is produced by the action of chlorine 
upon alcohol. It is a colorless, limpid, and neutral fluid, which is for 
practical purposes non-inflammable, although it can be made to burn 
with a greenish flame ( Fownes’s Chemistry , Am. ed., 1869, p. 566). Its 
taste is hot and sweetish, its odor fragrant and peculiar. It is sol¬ 
uble in alcohol and in ethei*, but when dropped into water it sinks, if 
pure, as transparent globules without milkiness. The alcoholic solu¬ 
tion, when moderately diluted with water, forms an aromatic, sweetish 
liquid. It is antiseptic, and does not coagulate albumen. 

In the U.S. Pharmacopoeia it is officinal in two forms. 

Chloroformum Yen ale—Commercial Chloroform. U.S.— The 
crude chloroform of commerce. Sulphuric acid, when shaken with it, 
after a time separates as a stratum of a dark-brownish color. This 
color is due to a carbonization by the acid of the impurities in the 
chloroform. 

Chloroformum Purificatum—Purified Chloroform. U.S.—The 
U.S. Pharmacopoeia directs that the commercial chloroform shall be 
purified by the action on it of sulphuric acid and by subsequent neu¬ 
tralization with carbonate of sodium, and distillation in a retort con¬ 
taining quick-lime. Purified chloroform should respond to the following 
tests: Sulphuric acid shaken with it should not be colored; it should 
not alter litmus blue, even after it has been exposed in a white glass 
bottle to direct sunlight for ten hours. 

Physiological Action.— Although somewhat of an anaesthetic, chlo¬ 
roform applied locally is a powerful irritant. On the skin it produces 
redness and burning; if the evaporation be restrained, vesication will 
be induced by it. Taken into the mouth, it causes a burning sensation, 
and, when swallowed, a sense of warmth in the stomach. 

The vapor of chloroform, when inhaled, produces symptoms seem¬ 
ingly similar to those induced by ether, except that the choking sensa¬ 
tions are absent, and that the stage of excitement is generally, but not 
always, shorter and less violent than is that of etherization. 

Dr. Snow (On Anaesthetics , London, 1858) divides the chloroform- 
narcosis into four degrees or stages, but the division adopted by Sabarth 
(Das Chloroform , Wurzburg, 1866) and most writers seems more useful. 
This classification recognizes three stages. In the first of these, the 
symptoms are similar to those of alcoholic intoxication. This stage is 
generally very short, but in athletic persons, and especially in those 
who have been intemperate, it may be very long and very violent, and 
may persist after loss of consciousness. In drunkards, this excitement 


144 


GENERAL REMEDIES. 


at times cannot be overcome without grave danger to life. During this 
first stage, although consciousness is not lost, the sensibility is gener¬ 
ally blunted, but very rarely is it altogether annulled. Dr. Coleman 
(Sansom, Chloroform , p. 55, Philadelphia, 1866) states, however, that he 
has extracted his own teeth without pain; and Dr. Snow relates the 
anecdote of a child who played with his toys during the operation of 
lithotomy. 

During the second stage, which is that of anaesthesia, the conscious¬ 
ness and sensibility are abolished, the muscles are relaxed, and the 
patient lies perfectly quiet. This is the surgical stage, during which 
ordinary operations are performed. As already intimated, in some cases 
the first and second stages are united, so that violent excitement, mus¬ 
cular spasm, and rigidity may coexist with loss of consciousness and of 
sensibility. 

The third stage is one of profound narcosis, with stertorous breathing, 
intense muscular relaxation, and abolition of ordinary reflex actions. 
This is always a condition of danger, and its induction by chloroform, 
except under very peculiar circumstances, is absolutely unjustifiable. 

The pulse in the first stage of chloroform-narcosis may be quickened, 
even apparently strengthened; in the second stage it is generally about 
normal in frequency, but is more or less weakened; in the third stage 
it may be rapid and weak. Dr. Hoel (London Med. Record , 1877, p. 457) 
calls attention to a cervical venous pulse, most marked in the external 
jugulars, which he asserts frequently occurs during the waking up from 
chloroformization. He believes it to be a symptom of serious cardiac 
embarrassment. E. Simonin found that the temperature usually rises 
during the first stage (.l°-.8° C.), falls slightly during the second or re¬ 
mains above normal, and falls decidedly during the third stage ( Centralbl. 
f. Chirurgie, 1877, p. 234). 

In man the first arrest of respiration, so obvious in etherization, rarely 
if ever occurs. This is probably in great measure owing to the chloro¬ 
form vapor, as employed, being much more dilute than the ether vapor. 
The experiments of Holmgren, Kratschmer, and others have shown 
that upon the lower animals the respiratory action of chloroform is 
similar to that of ether (see p. 138), except that it is much more 
intense. 

Dr. Baudin (Le Progres Med., Sept. 1874) called attention to the 
pupil as a guide in chloroformization, stating that, although at first it 
is uniformly dilated, afterwards it is uniformly immovably contracted, 
and that this is the period for operating. Schlager is in accord with 
Dr. Baudin; in one hundred and twenty out of one hundred and 
twenty-two cases observed, the pupil was dilated during the stage of 
excitement, and during complete anaesthesia narrowly contracted. He 
also states that if during anaesthesia the pupil returns to normal, more 
chloroform is required, but if it suddenly dilates, danger is imminent. 
At present, however, the condition of the pupil cannot be considered a 


ANAESTHETICS. 


145 


safe guide in anesthetization. Dogiel ( Reichert's Archiv fur Anat., 1866) 
affirms that in rabbits, during the stage of excitement, the pupil is con¬ 
tracted, during anesthesia dilated. Professor Schiff has strenuously 
combated the conclusions of Baudin ; and in a very careful series of 
experiments on animals Dr. W. H. Winslow found that the state of the 
pupil varies greatly in the same stage of anesthesia. Thus, in com¬ 
plete anesthesia, sometimes the pupil was widely dilated, sometimes 
contracted; and death sometimes occurred with a dilated, sometimes 
with a contracted pupil,—in the former case probably being syncopal, 
in the latter asphyxial ( Phila. Med. Times, vi. 275). 

The action of chloroform on the nervous system, like that of ether, 
is chiefly upon the brain and the spinal centres. Carter (Brit. Med. 
Journ ., Feb. 1867) found that very decided anaemia of the brain can be 
seen in animals subjected to its influence after the cerebrum has been 
laid bare; and accident in man (Amer. Journ. Med. Sci., 1860) has fur¬ 
nished the corroboration of his experiments. Bernstein (Schmidts 
Jahrbucher , Bd. cxlii. p. 227) has demonstrated that its action on the 
peripheral nerves is very slight. He found that there was no percepti¬ 
ble difference in the conducting power of the two ischiatic nerves of a 
frog chloroformed after one of its iliac arteries had been tied. It is 
doubtful how far the muscular excitement of the second stage is due 
to real spinal exaltation and how far it arises from other causes. Bert 
asserts (Comptes-Bendus, t. lxiv., 1867) that it is purely psychical, and 
that there is during the production of anaesthesia a steady lowering of 
reflex activity. He rests this assertion upon the fact that in animals 
chloroformed after section of the cord there is no motor disturbance 
below the point of section,—a fact which certainly demonstrates at 
least that the muscular excitement and the convulsions are cerebral. 

In some animals the first effect of the inhalation of chloroform upon 
the circulation is a decrease in the frequency of the heart’s action. 
Dogiel believes that this is due to a stimulation of the inhibitory centres, 
because he has found that it does not occur after section of the vagi. 
The after-increase in the rapidity of the pulse appears to be due, at 
least in part, to paralysis of the inhibitory centres, upon which chloro¬ 
form seems to act as upon the oculo-motor centres, producing in them 
at first excessive functional activity, but afterwards functional paralysis. 
Both Kratschmer and Ivnoll (see p. 138) have noticed in rabbits, when 
either ether or chloroform is inhaled through the nose, a momentary 
rise of arterial pressure corresponding to the arrest of respiration, and, 
like it, evidently produced by irritation of the peripheral trigeminal 
branches. 

The very careful experiments of the English Chloroform Committee 
(Med.-Chirurg. Trans., vol. xlviii. p. 326) proved that after the first half¬ 
minute of the inhalation of chloroform there is a progressive lowering 
of the arterial pressure. It would, a priori, appear probable that this 
is to some extent due to a vaso-motor paralysis; but Sansom and Harley 

10 


146 


GENERAL REMEDIES. 


state that there is a spasm of the small vessels, which can be readily 
seen to occur in the web of the frog during chloroformization. !Not 
until the third stage is reached, according to these authors, do the ves¬ 
sels relax into dilatation. If these observations are correct, chloroform 
first stimulates and afterwards depresses the vaso-motor centres. Else¬ 
where in the present work I have dwelt upon the fallacies of obser¬ 
vations like those just quoted, and the experiments upon arterial 
pressure of Professor H. P. Bowditch and C. S. Minot ( Boston Med. and 
Surg. Journ ., May, 1874) appear to prove that the fall of pressure is in 
part due to a paralysis of the vaso-motor centre. They found that after 
the exhibition of the drug in curarized animals galvanization of a sen¬ 
sitive nerve is followed by no rise of pressure, or a very slight one, 
and that compression of the carotids did not cause the customary vaso¬ 
motor spasm and rise of arterial pressure. 

On the heart itself chloroform undoubtedly exerts a steady, power¬ 
ful depressing influence. Injected into the jugular vein, it instantly 
arrests the heart’s action and destroys its muscular irritability.* Even 
the vapor of chloroform, when locally applied to the exposed heart, 
paralyzes it ( Edinb. Med. Journ., 1842). When artificial respiration is 
maintained, the effect of chloroform upon the heart is very apparent 
(Journ. Anat. and Physiol., xiii. 226). It is, therefore, demonstrated 
that chloroform applied in a sufficiently concentrated form destroys the 
contractile power of the heart-muscle. 

The respirations may at first be rendered slower by chloroform, but 
after a time are generally quickened, and as the inhalation is persisted 
in they become more and more shallow, irregular, and distant, and finally 
cease. 

In animals, without doubt, chloroform, when inhaled, usually pro¬ 
duces death by abolishing the functional power of the medulla oblon¬ 
gata, and thereby arresting respiration. It has been denied that chloro¬ 
form-vapor ever kills animals in any other way.I This is, however, a 
mistake.I If the chloroform-vapor be administered in a very dilute 
form, the heart generally will continue to beat for a long time after the 
cessation of respiration. If the vapor has been less diluted, cardiac 
and respiratory action may cease almost simultaneously. If the vapor 
has been administered in a concentrated form, arrest of the heart’s 
beat may precede arrest of respiration.§ 

When death is produced by chloroform in man, it is generally by 
cardiac arrest, sometimes by asphyxia. That syncope occurs propor- 


* Glover {Edinb. Med. Journ., 1S42), Gosselin {Arch. Gin., 1S48), Anstie, H. C. Wood, 
f See, especially, report of the French Chloroform Commission. Sabarth, Dag Chloro¬ 
form, p. 44. 

t Consult Snow, On Anesthetics, p. Ill; Anstie, Stimulants and Narcotics ; Richardson, 
Med. Times and Gaz., 1S70; Chloroform Committee, Medico-Chirurgical Transactions, vol. 
xlvii.; Yulpian, Lemons sur VAppareil vaso-moteur, vol. ii. p. 157. 

\ Compare Journ. Anat. and Physiol., xiii. 226. 



ANESTHETICS. 


147 


tionately more frequently in man than in animals, is simply because 
this form of death is sudden and unexpected. Asphyxia comes on 
gradually, so that in man the threatening symptoms are perceived, and 
death is averted by prompt measures. In animals, however, the object 
being to kill, nature is allowed to take its course.* 

The evidence is not at present sufficient to enable a positive deter¬ 
mination as to whether the action of the anaesthetic upon the heart, 
when a sudden fatal syncope is produced, is a direct one, or whether it 
is a reflex one (T. D. Lente, Psychological and Medico-Legal Journal, Feb. 
1875), due to an irritation of the peripheral filaments of the pulmonic 
nerves. 

The recent experiments of Vulpian upon chloral lend credibility to the 
theory that at least in some cases of chloroform-death the fatal result is 
produced by reflex cardiac inhibition. (See Chloral.) Even if this be 
correct, however, it does not follow that the original source of the im¬ 
pulse has been in the pulmonic nerves. It is notorious that in many 
cases syncopal death has occurred immediately after the first incision 
of the knife. Any such incision must of necessity give rise to a cardiac 
inhibitory impulse unless the inhibitory centre be completely paralyzed; 
and it has been shown by Vulpian that the heart under the influence 
of chloral, a substance closely allied to chloroform in its cardiac rela¬ 
tions, is extraordinarily sensitive to slight inhibitory impulses. It is 
not probable, however, that reflex inhibition is the sole or even the 
chief cause of heart-failure during chloroformization. Chloroform is a 
powerful cardiac depressant, and it is extremely probable that in many 
cases the syncope is the result of its direct influence upon the heart- 
muscle. The mere rapidity of the occurrence of the syncope after the 
first whiff of the chloroform is of little importance as an argument for 
the theory that death is caused by irritation of the peripheral nerves 
in the lungs, since the pulmonic absorption of chloroform is practically 
instantaneous and the blood goes directly from the lungs to the heart. 
The various other theories which have been brought forward to ac¬ 
count for chloroform deaths have not as much plausibility in them as 
has the theoiy of reflex syncope. I think they are unnecessary and 
unproved, though some are ingenious, and it is possible that death 
may take place at times in the way they suggest. The want of space 
prevents my further discussing the subject: references to the more 
important papers are given in the foot-note.f 

According to Harley (Physiological Transactions , London, 1865), 


* For proof that cardiac death does occur among animals, see Journ. Anat. and Physiol., 
xiii. 224. 

t Richardson, Medical Times and Gazette, 1870. Andrew H. Smith, New York Medical 
Journal, 1871, p. 46. Consult also J. C. Reeve, American Journal of the Medical Sciences, 
Oct. 1867; Henry M. Gibbons, Jr., Pacific Medical and Surgical Journal, June, 1869 ; Snow, 
On Anesthetics ; Sansom, On Chloroform ; and 0. W. Copeland, Philadelphia Medical Times, 
p. 550, 1874. 



148 


GENERAL REMEDIES. 


blood to which as little as five per cent, of chloroform has been added 
becomes very liquid and of a bright arterial hue. After a time crystals 
form in it. Boettcher ( Virchow's Archiv, vol. xxxii. p. 126) was, I be¬ 
lieve, the first to study these changes closely. The first alteration 
noticeable in the red blood-disks is a diminution of their size, which A. 
Schmidt and F. Schweiger-Seidel ( Berichte d. konigl. sacks. Gesellsch. d. 
Wissensch., math.-jJiys. Kl. , 1867, p. 190) assert to be due to contrac¬ 
tion, because when blood is treated with water until the red globules 
disappear, and carbonic acid gas is passed through the liquid until they 
reappear, on the addition of chloroform the sharply-contoured bodies 
will be seen to undergo marked contraction. As was first shown by 
Boettcher (Joe. cit., p. 127) and confirmed by Schmidt and Schweiger- 
Seidel, chloroform alone produces no other alteration than contraction 
in the red blood-disks. If, however, air be admitted to blood containing 
chloroform, the corpuscles rapidly disappear, dissolving in the serum, 
out of which, after a time, lisematoidin crystallizes. Both of the authori¬ 
ties quoted believe that the latter changes are due to oxidation. 

Boettcher states ( loc. cit., p. 129) that chloroform-vapor mixed with 
air converts enough of the oxygen of the latter into ozone to react 
with iodinized-starch paper; and Schmidt and Schweiger-Seidel have 
found that an excess of carbonic acid in the blood interferes with the 
changes caused by chloroform. From these facts it seems probable 
that their opinion as to the nature of the blood-changes is correct. 
Harley (loc. cit.) has studied the effect of chloroform on the absorption 
of gases in the blood. He states that when chloroform is added to 
fresh blood, and the mixture allowed to stand for twenty-four hours, a 
marked increase takes place in the proportion of oxygen and a lessen¬ 
ing in that of carbonic acid. This is in accord with the theory just 
mentioned; for, after the complete oxidation of the hsemato-globulin 
brought about by the chloroform, further consumption of oxygen could 
not occur, and, as it continued to be absorbed from the air, it must 
accumulate instead of being converted into carbonic acid. 

How far, during ordinary narcosis, chloroform produces the changes 
just described in the blood is somewhat uncertain; but it would seem 
very improbable that they occur to any great extent. A very sensi¬ 
tive test of the destruction of the red disks in the body is found in the 
production of icterus; and icterus never follows amesthesia. On the 
other hand, Husemann (Schmidt's Jahrbucher , Bd. cli. p. 84) intimates, 
on what authority I do not know, that after amesthesia bile-acids (the 
precursors of icterus) appear in the urine; and Bert (Journal of Anatomy 
and Physiology , May, 1870) has determined that the oxygen of the blood 
undergoes during ansesthesia an increase, such as Harley has found to 
happen when chloroform is added to blood outside of the body. ISToth- 
nagel (Berlin. Klin. Wochenschrift, 1866) found in rabbits, after sub¬ 
cutaneous injections of chloroform or ether, bile coloring-matter in the 
urine; but Kappeler (Pie Anaesthetica , Stuttgart, 1880), in twenty-five 


ANAESTHETICS. 


149 


eases of chloroform-narcosis, was not able to obtain a trace of biliary 
coloring-matter ( Zeitschrift f. Physiolog. Chem., viii.). 

Chloroform is undoubtedly, at least in part, eliminated as chloroform 
escaping with the breath, also with the urine. Fubini (Moleschott's 
Untersuchungen zur Naturlehre , Bd. xiii., 1882) discovered it in the urine 
five hours after its inhalation. Dr. A. Zeller believes that it is in part 
decomposed, because he has found the chlorides in the urine nearly 
doubled by its inhalation ( Zeitsch.f . Physiolog. Chemie, Bd. viii. p. 74). 

Albuminuria has been noticed both in animals and in man after chlo¬ 
roform-narcosis ( Gaz. Hebdom., Fev. 1884, 104; also Brit. Med. Journ., 
18S3, ii. 623). It is affirmed, also, that astigmatism has been produced 
by chloroform inhalations (Brit. Med. Journ., 1883, ii. 476). 

In autopsies on persons who have died during chloroform-anaesthesia 
the presence of gas in the vessels and in the heart has been frequently 
noted. The sources of this gas have been much discussed, and various 
authors have arrived at the conclusion that the gas was the cause of 
the fatal issue. The subject has recently been elaborately studied by 
Dr. Kappeler (Archiv f. Klin. Chirurg., 1887, Bd. xxxi. p. 373), who 
appears to prove that in most cases the gas has been produced by putre¬ 
factive changes occurring after death. Pirogoff, however, asserts that 
he has witnessed the throwing out of gas in the blood during life, but 
this observation stands alone. It is possible that the chloroform has 
some influence upon the capacity of the blood for holding gas. 

Therapeutics.— As an anaesthetic, chloroform possesses the advan¬ 
tages of quickness and pleasantness of operation, smallness of dose, 
and cheapness. These advantages are, however, so outbalanced by the 
dangers which attend its use, that its employment under ordinary cir¬ 
cumstances is unjustifiable. It kills without warning, so suddenly that 
no forethought or skill or care can guard against the fatal result. It 
kills alike the robust and the weak, the well and the diseased; even the 
previous safe passage through one or more inhalations is no guarantee 
against its lethal action. Statistics seem to indicate a mortality of 
about one in three thousand inhalations; * and hundreds of utterly un¬ 
necessary deaths have been produced by the extraordinary persistence 
in its use by a portion of the profession. It ought never to be em¬ 
ployed except under especial circumstances, as when a speedy action 


* See Richardson, Medical Times and Gazette, 1S70; Henry M. Gibbons, Jr., Pacific 
Medical Journal, June, 1869; Squibb, On Anesthetics, New York Medical Journal, April, 
1871. Lyman has collected 342 cases of death from chloroform against 27 from ether, and 
gives the ratio of death in anaesthesia as follows: chloroform, 1 : 5860 ; ether, 1 : 16,542. 
Nitrous oxide appears to be the safest of all the anaesthetics, its ratio, according to Rottenstein, 
being 1 : 100,000. 

The mixture of ether and chloroform used by some surgeons is open to the very serious 
objection that owing to the different volatility of the two agents the percentage of each in 
the inhaled vapor varies continually. The mixture has in several cases produced death, 
and is probably no safer than pure chloroform. For fatal case, see Compt.-Rend. Soc. Biolog., 
1883, iv. 241. 



150 


GENERAL REMEDIES. 


is desired in puerperal eclampsia, or when the more bulky anaesthetics 
cannot be transported, as in the field during war-time. 

In obstetric cases, chloroform has been used even by those who give 
the preference to ether in surgery. So far as I know, no death has as 
yet occurred from chloroform during parturition , although alarming 
effects have been induced. The excitement of child-birth seems to 
fortify the system against the deleterious influence of chloroform. But 
even in these cases I think ether is just as useful as, and much safer 
than, its sister-anaesthetic. 

Various mechanical inventions have been made for the administra¬ 
tion of chloroform; but these inhalers do not appear to offer any 
advantages over the simple napkin, and, at least in this country, are 
rarely, if ever, used* A handkerchief or towel may be folded into a 
bird’s-nest shape, and twenty or thirty drops of the anaesthetic be put 
upon this and then held close to the mouth. Dr. Simpson advises that 
a towel be laid over the mouth and nose, and the chloroform slowly 
dropped upon this until anaesthesia is induced. Whatever plan be em¬ 
ployed, it is of vital moment that the vapor be well diluted; not more 
than three and one-half per cent, of it should be contained in the inspired 
air. 

When administered by the mouth in sufficient quantity, chloroform 
produces symptoms similar to, but much more permanent than, those 
which it causes when inhaled. It is, however, veiy rarely, if ever, 
used in this way for its constitutional effect, but is sometimes of ad¬ 
vantage in severe neuralgia. When quinine for any reason cannot be 
administered in an ague, a sufficient dose of chloroform (f5ss to fji) 
to produce a mild narcosis, given just before tfie expected time for the 
recurrence of the chill, Avill usually abort it. 

Chloroform by the mouth has been also highly recommended as a 
vermifuge in cases of tape-worm, but is of very doubtful value. 

When chloroform is taken into the stomach, a considerable portion 
of it is, without doubt, evaporated, so that the intestinal canal becomes 
filled with the vapor. Chloroform, therefore, when so placed exerts 
both a local anodyne and a stimulant carminative action. For this 
reason it is extremely valuable in all cases of colic, and it will often 
even assuage the pain of colica pictonum. 

Externally, as a rubefacient and anodyne, chloroform is very largely 
combined with other substances into liniments, which are especially 
useful in cases of chronic neuralgic or rheumatic pains. 

Toxicology.— Death may occur at any time during the inhalation 
of chloroform. In some cases it has seemed to be instantaneous, but 
generally it is preceded by symptoms such as a change in the expres¬ 
sion of the face, which becomes very pale or livid, evident irregularity 


* For a description of inhalers, see the works of Sansom and Snow; also Allis, Phila. 
Med. Times, vol. iv. 



ANESTHETICS. 


151 


of the respiration, and failure of the pulse: a shudder, or a violent 
convulsion, or even a sudden access of maniacal excitement, has been 
noted in some cases. After death the heart is almost always found 
relaxed, distended, and its right side filled with blood. 

When death is threatened through asphyxia, the alternate dash¬ 
ing of very cold and very hot water upon the face and upper chest 
is often very efficacious. Artificial respiration should be commenced 
at once. Faradization of the diaphragm, by pressing one pole firmly 
against the pit of the stomach and placing the other over the larynx 
and the root of the neck, has acted very favorably in some cases. Dr. 
Richardson has shown ( loc. cit .) that there is a danger of the excita¬ 
bility of the muscle being exhausted by a prolonged use of the galvanic 
stimulus. The application should not, therefore, be long continued, but 
should be alternated with artificial respiration. Whenever there is any 
failure of the heart’s action, as is nearly always the case, the body 
should be laid at an angle of 40°, with the head downwards, so as to 
favor the passage of arterialized blood to the brain (Dr. E. L. Holmes, 
Chicago Medical Journal, Sept. 1868).* 

In artificial respiration, act with the patient, and not against him. 
He will usually not cease to breathe at once, and wholly. Enjoin 
silence; watch the first attempt at inspiration, and at the expiration 
compress the thorax, aiding its elastic reaction, if absolutely necessary, 
by Silvester’s or some other quiet method. See that the tongue is well 
forward. Dry external heat must be vigorously used, and the inspired 
air should be at from 80° to 85° F., or even higher. Frictions and 
passive motion, to aid in the circulation, must not be forgotten. Efforts 
at resuscitation should be kept up for at least two hours. Nitrite of 
amyl has been used as a means of restoring the heart’s action, and 
should be tried (see N. Y. Med. Journ., xxiv. 467). Ammonia injected 
into a vein, and digitalis hypodermically given, may be used to stimu¬ 
late the circulation, but alcohol, if employed at all, must be given very 
cautiously and with the utmost reserve.f Its action upon the heart 
when in excess is precisely that of chloroform, and the experiments of 
R. Dubois (Progres Med., 1883, xi. 951) show that when alcohol is given 
freely to the lower animals it intensifies the influence of chloroform 
and lessens the minimum fatal dose. In synccqie during ether-narcosis, 
alcohol should never be used. 


* I have allowed this sentence to remain as it was in the first edition. Since the book 
was first published, the method has been brought forward as new, and as having originated 
with NAlaton (Philadelphia Medical Times, vols. iv. and v.) The position of the patient is 
of extreme importance. In severe cases the head should be placed vertically downwards. 

f A method of treating diastolic arrest of the heart in chloroform-anmsthesia, which on the 
face of it appears of exceedingly doubtful advantage, has been proposed by Dr. B. A. Watson 
(Journ. Amer. Med. Assoc., 1887) upon the basis of some sixty experiments made upon dogs 
with asserted good results. It consists in the puncture of the right ventricle by an aspi¬ 
rating-needle and consequent withdrawal of blood. Both Kronecker, of Berne, and Mills, 
of Montreal, insist that this procedure is not only useless, but very dangerous. 



152 


GENERAL REMEDIES. 


Poisoning has been produced by the swallowing of chloroform. 
The symptoms induced have been stupor, with contracted, or, in later 
stages, dilated, pupils, and a stertorous respiration, which finally be¬ 
comes very irregular, shallow, and often distant. The amount neces¬ 
sary to destroy life probably varies greatly, but, according to L. Lewin, 
a single drachm has produced death. In some cases ( N. Y. Med. Bee ., 
July 11, 1885) the fatal result has occurred from secondary gastritis 
eight days after taking the medicine; and not rarely violent gastritis 
with jaundice apparently from inflammation of the gall-ducts has fol¬ 
lowed the taking of a poisonous dose of chloroform. Eecovery has 
occurred after the ingestion of two ounces (Stille, Therapeutics , vol. ii. 
p. 107), of one ounce ( Canada Lancet , March, 1874), also of three ounces 
without vomiting (Brit. Med. Journ., 1882. i. 776). The treatment 
consists in the use of the stomach-pump and of the various ordinary 
methods of arousing a narcotized patient, especially the alternate cold 
and hot douche, artificial respiration, and the very cautious use of 
diffusible stimuli if required. Death may occur during the narcosis, 
or the patient may survive this and perish from inflammation of the 
trachea, oesophagus, and stomach, caused by the local action of the 
chloroform. 

The recognition of chloroform as the probable cause of any given 
death cannot be based upon the post-mortem appearances. Indeed, the 
latter are of no value in deciding such a question. The anaesthetic may, 
however, be recovered by distillation of the lungs and blood within a 
certain period of time after death. As to the length of this time, so 
far as I am aware, no investigations have been made. 

Experiments made at the Philadelphia Hospital and confirmed by 
Professor Dolbeau (Annales d’Hygiene , Jan. 1874) have proved that 
persons sound asleep may be chloroformed without being awakened. 
Anaesthesia cannot, however, be produced in any one partially awake, 
or even sleeping lightly, without his knowledge. 

Quite a number of professional men have been accused, and some 
convicted on the charge, of committing rape on females in whom they 
had induced anaesthesia. No doubt the women believed that they 
had been violated; but it is certain that in many of the cases, and 
probable that in all of them, they mistook for the real act the subjec¬ 
tive erotic sensations induced by the chloroform or ether. The value¬ 
lessness of the testimony of persons as to occurrences during the time 
of their intoxication with anaesthetics should be recognized by law as 
a governing principle of evidence. 

Administration.— Internally, from fifteen drops to a fluidrachm of 
chloroform may be given in emulsion, or, as it has recently been stated, 
dissolved in glycerin (1 to 3). The deep injection of half a drachm of 
chloroform has been recommended very strenuously by Professor Bar- 
tholow in obstinate neuralgia , and has found some favor in France (Bull. 
Therap ., xciii. 433, 471). In the only case in which I have tried it, 


ANAESTHETICS. 


153 


one of trigeminal neuralgia, the local symptoms caused by it were so 
severe as to imperil the life of the patient. The U.S. Pharmacopoeia 
recognizes a spirit (,Spiritus Chloroformi, 1 to 10, U.S.), dose, one to two 
fluidrachms, and a mixture (Mistura Chloroformi , U.S.); also, made from 
commercial chloroform, a liniment {Linimentum Chloroformi , U.S.). 

Bichloride of Methylene was introduced to the notice of the 
profession by Dr. B. W. Richardson {Med. Times and Gaz., 1867, p. 478) 
as an anaesthetic similar to, but more pleasant and possibly safer than, 
chloroform, and has been rather extensively used in London. It has 
never been largely employed in this country. There is no way of 
knowing how many times it has been administered, but nine cases 
of death from its use are recorded {Brit. Med. Journ., 1883, ii. 104). 
The detailed phenomena in some of these cases indicate that, like 
chloroform, the bichloride of methylene kills by paralyzing the heart. 
It is not probable that it will ever come into general use as an anaes¬ 
thetic. 

Bromide of Ethyl* has been used as an anaesthetic, and at one 
time bade fair to become very popular. The occurrence of two deaths 
during its use, however, early arrested its successful career. It is a 
very prompt anaesthetic, in most cases acting even more quickly than 
does chloroform, but less agreeably to the patient. Recovery is very 
prompt. Its action upon the heart is the same as that of chloroform. 
Injected into the jugular vein, it arrests the heart, and one death pro¬ 
duced by it was distinctly by syncope. In some cases it has seemed 
very irritant. It appears to be quite as dangerous as chloroform, and 
will probably never be used to any extent in practical medicine. 

Bromoform. —According to the researches of Bonome and Mazza, 
this substance acts as a general amesthetic both upon man and upon 
the lower animals, causing, however, much irritation of the conjunctiva 
and the nasal mucous membrane. The narcotic stage is slowly de¬ 
veloped and passes off slowly; the blood-pressure sinks somewhat; 
the respiration is not disturbed ; the irritability of the brain-cortex is 
diminished. Bromoform is said also to be a powerful antizymotic 
(Centralblatt f. Chirurgie, 1884, 594). I see no reason for believing that 
bromoform will be of any value as an amesthetic. See also Wien. Med. 
Jahrb., 1883, p. 497. 


* In a valuable paper (Amer. Journ. Med. Sci., July, 1881) Dr. E. T. Reichert adduces much 
evidence to show that all anaesthetics containing a halogen are cardiac depressants. He 
makes out his case sufficiently at least to warrant great caution in the use of any such anaes¬ 
thetic. 



FAMILY IH.-SOMYIFAOIEYTS. 


In the family somnifacients are placed in this treatise those drugs 
whose chief use in practical medicine is for the production of sleep. 
The alkaloid hyoscine is a hypnotic: it belongs, therefore, to the 
present family, and ought, theoretically speaking, to be considered in it. 
In nature hyoscine, however, is closely associated with the mydriatic 
alkaloid hyoscyamine, which dominates all the crude preparations con¬ 
taining hyoscine, and it is somewhat more convenient to discuss it along 
with that mydriatic alkaloid under the heading of Hyoscyamus, the 
crude drug from which both are derived. 

OPIUM. U.S. 

The inspissated juice of the unripe capsules of the Papaver somni- 
ferum, or poppy. It is obtained by incising the capsules with a small, 
sharp knife, and twenty-four hours afterwards scraping off the exuded 
juice with a blunt blade. Opium is produced in various parts of the 
world,—chiefly in Turkey, Asia Minor, Persia, and India, but also to a 
very slight extent in England, Germany, and the United States. Our 
market is almost exclusively supplied from Asia Minor, with the variety 
known as Smyrna or Turkey Opium. This occurs in masses from the 
size of the fist to that of a child’s head, irregularly globular, more or 
less flattened, covered externally with the capsules of a species of 
Eumex or dock, hard externally, softer and of a reddish-brown color 
within, and of a strong narcotic odor and taste. 

Smyrna opium is at times variously adulterated with gum, liquorice, 
and other substances. Such specimens are said generally to want the 
Eumex capsules. A rough but pretty fair test of the purity of opium 
is performed by drawing a piece of it across a sheet of white paper. 
'If it be much adulterated, the mark will be continuous,—not inter¬ 
rupted, as it should be. Often the black color, the adhesive consistency, 
and the sweetish taste will also betray the nature of the sample. 

On exposure to the air, opium becomes hard and brittle, and is 
readily reduced to a powder of a yellowish-brown color. It yields to 
water, alcohol, and diluted acids, forming dark-brown solutions. Ether 
does not extract all of its medicinal principles. It is a very complex 
body, containing the alkaloids morphine, codeine, narceine, narcotine, 
thebaine, papaverine, porphyroxine, cryptopine, meconine, opianine, and 
154 



SOMNIFA CIENTS. 


155 


paramorphine, besides meconic, thebolactic, and sulphuric acids, extrac¬ 
tive matter, gum, glucose, fixed oils, a volatile odorous principle, and 
other substances of no importance. In regard to the proportions of 
the more important principles, Messrs. Smith, of Edinburgh, obtained 
from 100 parts of fine opium 10 parts of morphine, 6 of narcotine, 1 
of papaverine, 0.15 of thebaine, 0.03 of codeine, 0.01 of meconine, 0.02 
of narceine, and 4 of meconic acid ( Pharm. Journ. and Trans., October, 
1865, p. 183). Good opium should yield from nine to fourteen per cent, 
of morphine. 

As meconic acid strikes a blood-red color with a persalt of iron, 
the latter affords a ready, although not decisive, test for opium and the 
meconates. 

Physiological Action. —When opium is taken in such dose as to 
produce its mildest physiological effects, it exerts a quieting influence, 
inducing a peculiar dreamy condition,—very generally a feeling of bien- 
faisance ,—during which images and ideas float before the mind, and by 
their endless and effortless repetition shorten the time, which seems to 
lose itself in rest. It is commonly asserted that there is a stage of 
the action of opium in which the activity of the mental faculties is 
exalted. This may be so in some persons, and especially in those who 
have accustomed themselves to the use of the drug as a stimulant; but 
my experience is that in those who do not habitually take opium true 
mental power is, during all the stages of the action of the drug, dimin¬ 
ished rather than increased. The state induced is rather the fabled calm 
of the lotus-eater than the energetic activity of production. Even in 
those who are accustomed to the use of opium as an aid to work, I 
think it is the imagination rather than the reasoning faculty that is 
excited by it. After a length of time, varying according to the idio¬ 
syncrasies of the patient and the dose of the drug, the condition which 
has been noted gradually passes into sleep,—either light and dream¬ 
ful, or natural, or heavy and deepening into stupor, according to the 
amount of the drug ingested. On awakening, the patient may return 
at once to his normal condition, but very often he experiences a state 
of depression, as shown by languor, a little headache, nausea, or even 
vomiting, which may last for some hours. 

After very large doses, the first stage of the action of opium is very 
short, or it may be entirely wanting, sleep coming on almost at once. 
Thus, I have seen deep coma produced in three minutes by a hypo¬ 
dermic injection of morphine. The symptoms of the second stage of 
opium-poisoning closely resemble those of congestion of the brain : the 
pupils are strongly contracted; the face is more or less suffused, often 
deeply cyanosed; the pulse full, slow and strong; the skin generally 
dry and warm; the respiration slow and deep, and, it may be, ster¬ 
torous ; unconsciousness is apparently complete, though generally the 
subject can be aroused by violent shaking or by shouting in his ear, but 
relapses at once when left to himself. When the patient is aroused, the 


156 


GENERAL REMEDIES. 


respirations become more rapid, and the skin often regains almost at 
once its normal color. Death very rarely occurs during this second 
stage of opium-poisoning. When the symptoms do not gradually 
ameliorate, the third stage, that of prostration, is developed. The 
coma is now profound, and to arouse the patient may be impossible; 
the pupils are absolutely contracted, or, as death approaches, are 
widely dilated; the respirations are distant, slow, feeble, and imper¬ 
fect, and often interrupted by intervals of death-like quiet; the coun¬ 
tenance is at once pallid and cyanosed; the pulse grows more and more 
rapid and more and more feeble; the skin is cold and moist, finally 
becoming covered with a clammy sweat. Even yet the patient may 
recover: if he do so, the return to life is very gradual; if he do not, 
death occurs generally by failure of the respiration, but amid an almost 
complete extinguishment of the vital functions. 

Although the symptoms which have been narrated are those usually 
produced by opium, yet in certain individuals the drug provokes quite 
different phenomena. One of the most common of these departures 
from the ordinary course of symptoms is an excessive depression fol¬ 
lowing the sleep produced by moderate doses of the medicine. This 
state is seen, so far as my experience goes, most usually in females of 
weak, nervous organization, such as are peculiarly liable to attacks of 
neuralgia. The symptoms are a feeling of weakness and prostration, 
often accompanied by chilliness, dull headache, and giddiness, but es¬ 
pecially marked by intense nausea and frequent vomiting. Very fre¬ 
quently the latter does not occur so long as absolute rest in the hori¬ 
zontal position is maintained: indeed, an almost diagnostic sign of this 
affection may be found in the fact that the stomach is quiet so long as 
the patient keeps the head upon the pillow, but the distress occurs at 
once upon rising up. In some cases this condition of depression even 
replaces the normal second stage, so that opium, instead of inducing 
quiet sleep, will provoke alarming depression and vomiting, either with 
or without drowsiness. Thus, cases have been reported in which one- 
fourth of a grain, or a somewhat greater quantity, of morphine, hypo¬ 
dermically injected, has been followed at once by syncope, with strug¬ 
gling for breath, and apparently imminent or even present death.* A 
rarer idiosyncrasy exists in those persons who are rendered by opium 
very delirious, it may be even wildly so. In certain cases of opium¬ 
poisoning, partial or complete convulsions have occurred amidst the 
more usual phenomena. (Cases, Brit. Med. Journ., 1876, ii. 496 ; Pacific 
Med. and Surg. Journ., July, 1876.) Severe itching of the skin is a 
common phenomenon when the action of opium is going off, and 
there are persons in whom such violent erythema is produced even by 


* See Report of the Committee on the Hypodermic Method of Injection, Medico-Chirur- 
gical Transactions, vol. i.; see also Medical Times and Gazette, 1868, cases reported by Mr. 
Braine and by Mr. Roberts. 



SOMNIF A Cl ENTS. 


157 


therapeutic doses as to forbid the use of the drug (case, Wien. Med. 
Presse, xxiv. 568). 

Opium at first sight appears to act so differently upon the lower 
animals from the way in which it acts upon man, that it seems neces¬ 
sary to discuss the former action by itself. 

In 1826, Charvet ( Pereira's Materia Medica , vol. ii. p. 1035, Phila¬ 
delphia, 1854) found that opium acts upon all classes of animals, in¬ 
ducing in the invertebrata weakness or paralysis of the contractile tis¬ 
sue, with gradual sinking and death: in fishes, a weakened paralytic 
condition of the muscular system, associated with convulsions ; in birds 
and mammals, paralysis, convulsions, and stupor. These researches 
have been recently much extended, but in considering them I shall 
confine myself to the vertebrata. 

When one or two grains of opium are injected under the skin of a 
frog (Kolliker, Virchow s Archiv, Bd. x. p. 248; J. F. H. Albers, Virchow's 
Archiv, Bd. xxvi. p. 229), in from six to ten minutes a condition of 
excitability is induced, so that the least touch produces violent tetanic 
convulsions, which, a little later, also occur without obvious cause. 
After a time, these convulsions gradually give way to a deepening 
paralysis. The breathing, previously disturbed, becomes more and 
more shallow and imperfect, and finally is suspended. Morphine acts, 
apparently, on frogs in the same manner as opium: at least Drs. Rich¬ 
ard Gscheidlen ( Untersuchungen aus dem Physiolog. Laboratorium in 
Wurzburg, Bd. iii. p. 15) and W. Baxt (. Reichert's Archiv fur Anatomie , 
1869, p. 128) have found that in large doses it induces the counter¬ 
part of the series of phenomena just described. The latter observer 
noted, however, that when a minute dose (15.25 milligrammes) was 
employed, immediately following the injection came a brief period of 
disquietude; one minute afterwards the frog returned to its normal 
state, in from six to ten minutes suffered a diminution of excitability, 
and in from twelve to fifteen minutes fell into a stupor which continued 
from four to ten hours. After awakening, the reflex excitability seemed 
greater than normal.* 

According to Kolliker, the opium-convulsions take place after the 
cord has been divided below the medulla, or even as low down as the 
third vertebra. In a single experiment, tetanus did not occur after 
division of the cord at the fifth vertebra; but the quietness was prob¬ 
ably simply due to exhaustion, as the frog had already been poisoned 
for a length of time and had suffered section of the medulla and of the 
cord below the medulla. These facts seem to prove that the convul¬ 
sions are reflex and of spinal origin. That the reflex centres of the 
cord are excited, Gscheidlen has confirmed by direct experiment, and 


Dr. S. Meihuizen affirms ( loc. cit.) that this increased reflex activity is only towards 
chemical and not towards mechanical irritation. This is, however, opposed by such a mass of 
experimental evidence that I think it must be incorrect. 



158 


GENERAL REMEDIES. 


has also proved that in the latter stages, when the motor functions are 
depressed, the paralysis is largely of spinal origin, the reflex activity 
of the cord being greatly lessened. The convulsive movements which 
are present late in the poisoning would appear, however, to be of 
peripheral origin: at least, in Albers’s experiments (loc. cit.') they 
occurred in limbs whose nerves had been previously cut so as to sever 
all connection with the nerve-centres. Further, both Kolliker and 
Albers assert that some of the convulsions are epileptiform,— i.e ., 
of cerebral origin; and Dr. S. Meihuizen ( Arch . /. Physiolog ., vii., 
1873) states that the convulsions occur at a time when mechanical 
irritation fails to induce any response. If these experimental results 
be correct, opium apparently induces in the frog three kinds of con¬ 
vulsions, of which those of reflex origin are probably the chief. 

Kolliker, from his investigations, concluded that opium does not act 
upon the peripheral nerves of frogs; but the recent very elaborate 
and apparently accurate experiments of R. Gscheidlen ( Untersuchungen 
aus dem Physiolog. Laboratorium in Wurzburg , zweiter Theil, 1869, p. 1) 
have shown that morphine in small doses increases the excitability of 
the motor nerves and afterwards depresses them; after large doses the 
period of excitation is short, that of depression soon coming on; and 
after enormous doses diminution of functional activity is at once mani¬ 
fested. Both Gscheidlen and Kolliker agree that neither the contrac¬ 
tile power of the muscles nor the excitability of the motor nerves is 
destroyed by opium or morphine, although Albers ( Virchow's Archiv, 
Bd. xxvi.) asserts that both are extinguished. Gscheidlen calls atten¬ 
tion to this disagreement, and states that he has verified his own results 
by frequent experimentation with enormous doses of the alkaloid. 

Experiments upon the sensory nerves are always unsatisfactory, but 
Gscheidlen (loc. cit., p. 17), employing the method of Pfliiger, found 
that morphine locally applied intensifies and protracts the excitability 
of an afferent nerve in cases of strychnic poisoning* 

Our knowledge of the action of morphine upon the nervous system 
of the frog may be summed up as follows: 

Morphine in minute, non-toxic doses causes sleep, followed by aug¬ 
mentation of reflex activity; in large toxic doses it produces violent 
convulsions, followed by paralysis. The convulsions are chiefly spinal, 
and due to a heightened spinal activity, but are to some extent prob¬ 
ably, also, of cerebral origin, and later in the attack arise from a direct 
action of the alkaloid upon the muscle or the nerve-endings therein ; 
the paralysis is caused by a depression of the cord and a diminution 
of the conducting power in the nerves. 

Dr. S. Weir Mitchell has shown (. American Journal of the Medical 


* Perhaps it is appropriate here to call attention to a paper by Dietl and Vintschgau 
( Pfluger’s Arch., Bd. xvi.), in which it is attempted to be experimentally shown that morphine 
increases, caffeine lessens, and alcohol first lessens and then increases the time required by the 
nervous system for the recognition of a peripheral irritation. 



SOMNIFA Cl ENTS. 


159 


Sciences , Jan. 1869, and Jan. 1870) that birds, as represented by pigeons, 
chickens, and ducks, are very insusceptible to the toxic action of opium 
and its chief derivative, morphine. It appears to be impossible to 
kill a pigeon by opium given by the mouth, and of morphine from 
eight to fifteen grains are required to produce a fatal result; but when 
given hypodermically from two to three grains of the alkaloid suffice. 
These results have been in great measure confirmed by Dr. B. W. Rich¬ 
ardson, and are no doubt accurate. The symptoms induced have been 
very uniform: they are unsteadiness, labored breathing, increasing 
signs of dyspnoea, unaltered pupils, and, finallj’, general convulsions and 
death. Ho true hypnotic effect has been observed, but a curious and 
very great rise of temperature just before death was noted in one case. 
As Flourens affirms that a single grain of the aqueous extract of 
opium will throw a sparrow into a profound stupor, it can scarcely be 
considered as proved that the drug acts upon all birds as upon those 
experimented with by Dr. Mitchell. 

Upon dogs morphine acts very much as upon man.* In very many 
cases, if not in the majority, eight to ten grains of the alkaloid injected 
into a dog of moderate size will cause deep sleep, amounting to coma, 
so that the animal will remain in any position in which he may be 
placed. The length and depth of this sleep are, of course, proportion¬ 
ate to the dose: when at all profound, it is accompanied by marked in¬ 
sensibility to pinching and other forms of external irritation. A repeti¬ 
tion of irritation, and especially a sudden loud noise or shaking, will, 
however, arouse the animal, precisely as in man. Indeed, sometimes 
the dog, even when comatose, seems more than normally sensitive to 
sudden noise, trembling and starting in an almost convulsive manner. 
After awaking, the dog shows unmistakable signs of nervous and psy¬ 
chical depression. In walking, the hind legs are dragged, as though 
semi-paralyzed; the eyes are haggard; the naturally brave animal 
cowers in a corner or seeks to hide himself, no longer recognizing his 
master, and does not return to his natural condition for many hours. 
After smaller doses the effects are proportionately less intense. It has 
been shown by Harley that in some dogs, precisely as in some people, 
morphine fails to exert its usual hypnotic action, but produces great 
depression, as evinced by faintness, prolonged nausea, and retching, 
interrupted only by intervals of dreamy delirious somnolency. 

In the horse (Harley, loc. cit.), two or even three grains of morphine 
hypodermically injected produce sometimes a slight drowsiness, some¬ 
times no perceptible effect. Doses of from four to six grains cause great 
restlessness and accelerated pulse. The mouth is moist, the temperature 
of the skin and its secretion increased; the animal paws continually, 


* Harley, The Old Vegetable Neurotica, p. 107, London, 1869; Claude Bernard, Archives 
Ginirales, ii. 437, 6th series, 1864; J. J. Reese, American Journal of the Medical Sciences, 

Jan. 1871. 



160 


GENERAL REMEDIES. 


and treads about in his stall with an almost rhythmical movement. 
After twelve grains, Harley noticed in some cases very great excite¬ 
ment, as shown by marked increase in the rapidity of the heart’s action, 
by muscular rigidity and tremors, and by the animal’s walking rapidly to 
and fro, slobbering and sweating profusely. In another horse, after an 
immediate strong erection of the penis and copious emission of semen, 
heavy sleep came on, interrupted after the third hour by the usual 
symptoms of excitement. Thirty-six grains of the acetate of morphine 
caused in a powerful hunter deep comatose sleep, commencing in fifteen 
minutes and lasting for three hours, when it was replaced by intense 
restlessness and severe delirium, continuing for seven hours. During 
this time the animal was perfectly blind. 

Barbier’s previous experiments upon the horse (quoted by Professor 
Stille) yielded results similar to those of Harley. He used larger doses, 
and found that four drachms of the aqueous extract of opium pro¬ 
duced violent tremblings, apparent insensibility to external irritants, 
convulsions without coma, and death. One hundred grains of the 
acetate of morphine killed a horse by convulsions in three hours. 

In the mouse, according to the experiments of Harley, the first effect 
of an injection of from one-twentieth to one-twelfth of a grain of mor¬ 
phine is a tonic cramp-like contraction of the muscles, especially of the 
trunk, of such character that periods of forced rest alternate with a 
slow, laborious creep, which seems to originate not in the limbs but in 
the trunk itself. There is in this state no tendency to somnolency, but, 
on the contrary, an abnormal sensitiveness to loud sounds, which cause 
the mouse to l’esume for a moment active running movements. The 
breathing is irregular, the pulse accelerated, and finally stupor develops 
itself, and coma deepens into death by dyspnoea; or, otherwise, recovery, 
preceded by convulsive movements of the hinder part of the body, is 
gradually brought about. 

In reviewing the action of morphine upon the lower animals, it 
becomes very evident that while we are not in a position to explain 
all the symptoms, yet two classes of phenomena are everywhere dis¬ 
cernible,— i.e., the spinal and the cerebral,—and that the higher in the 
scale of life any given animal may be, the more marked are the brain- 
symptoms. These cerebral phenomena are mostly sleep and stupor; 
but, as is well known, in some human individuals morphine acts as a 
delirifaeient; and it seems very probable that the peculiar restlessness 
of the horse under the influence of the alkaloid is due to delirium, and 
not to spinal excitement. 

When looked at in this manner, it seems to me that morphine does 
not act so differently as is generally believed upon the lower animals 
and upon man. The immensely higher cerebral organization of the 
latter, with the immensely greater sensitiveness which it involves, makes 
the man correspondingly more susceptible to the cerebral action of the 
drug: hence not only is he affected by much smaller doses of the alka- 


SOMNIFA CIEN TS. 


161 


loid than are the lower animals, but as the spinal symptoms are trium¬ 
phant in the frog because its spinal system is vastly more developed 
than its cerebral, so in man the cerebral symptoms mask the spinal 
because in him the brain is more developed than the cord. The two 
creatures—man and the frog—occupy the two extremes of the series; 
between them is probably to be found every gradation.* 

The action of opium upon dogs and rabbits is sufficiently close to 
that upon man to enable us to reason from experiments upon the former 
as to the influence of the alkaloid upon the circulation and respiration 
in the latter. Indeed, so far as these functions are concerned, morphine 
appears to act identically in both instances. 

Action on the Circulation. —In man, the circulatory phenomena are a 
slight primary evanescent acceleration of the pulse-rate (see Nothnagel, 
Handbuch der Arzneimittellehre , Berlin, 1870, p. 8), succeeded by slowing 
and increased fulness and force of the pulse, which is followed by a 
return to the normal pulse, or a great increase of rapidity and loss of 
strength, during the third stage. It. Gscheidlen has found in rabbits 
and dogs after the injection of morphine, first an increase in the pulse- 
rate, then a decrease, and finally return to the normal pulse, or else 
increased rapidity. Sphygmographic studies of the effects of small 
doses of morphine have been made with various results by several ob¬ 
servers : undoubtedly in some individuals therapeutic amounts of the 
alkaloid depress sensibly the circulation, but, in agreement with Riegel 
and Priesendorffer ( Deutsches Archiv , Bd. xxv. p. 48), it can scarcely 
be doubted that therapeutic doses have no sensible effect upon the 
circulation in the ordinary man. 

The slow, full pulse of the second stage of opium-poisoning is due 
to an action of the drug upon the inhibitory cardiac nerves, as may 
also possibly be in some manner the increased arterial pressure; for 
Gscheidlen ( loc. cit., p. 45) has experimentally demonstrated that after 
section of the vagi morphine is powerless to lower the pulse, and also 
that division of the nerves during the second stage of morphine-poison¬ 
ing is followed by an extraordinary rise in the pulse-rate. That the 
peripheral ends of the vagi are stimulated was proved by the fact that 
cardiac arrest took place when the distal ends of the cut nerve were 
more feebly irritated than would suffice to affect the unpoisoned animal; 
and that the inhibitory cerebral centres are stimulated was demon¬ 
strated by the instantaneous very great fall of the pulse-rate-, amounting 
in some cases to one-half in less than half a minute-, whicht ensued 
upon the injection of a large dose of the alkaloid into the carotid,— 
i.e., into the brain and the inhibitory centres. The- rapid feeble pulse 
of the third stage of opium-poisoning Gscheidlen found to be due, at 

* A curious corroboration of the views expressed in this paragraph is found in the fol¬ 
lowing sentence taken from Althaus (Diseases of the Nervous System, New York, 1878, p. 
135): “ In infants, however, and also in the lower races of mankind, as in negroes and Malays, 
convulsions are observed after its [opium] ingestion.” 

11 



162 


GENERAL REMEDIES. 


least in a measure, to paralysis of the peripheral vagi; for at such time 
stimulation of the peripheral end of the cut nerve was powerless to 
affect the heart. 

The experiments of G-scheidlen also indicate that morphine exerts 
first a stimulating , then a depressing influence upon the heart-muscle or 
ganglia , since, after isolation of the viscus by section of the cord, sympa¬ 
thetic, and pneumogastric, life being sustained by artificial respiration, 
a large dose of morphine induced a momentary increase in the number 
of the cardiac contractions, followed by a marked decrease and finally 
extinguishment of the same. This conclusion is confirmed by the experi¬ 
ments of Drs. Sydney Ringer and H. Sainsbury (Brit. Med. Journ., March, 
1883), who found that opium first increased the power of the cut-out 
heart of the frog, then depressed it, and finally caused diastolic arrest. 

The question of the action of morphine upon the vaso-motor system 
is of great interest, but cannot at present be fully answered. Gscheidlen 
believes that it first stimulates and then depresses it, and asserts that 
after the injection of a large dose the arterioles in the mesentery can 
he seen to contract, and later (third stage) to dilate. The objections to 
this sort of evidence are sufficiently stated elsewhere in this book; and 
the rise of the arterial pressure, which he also adduces as an argument, 
may be accounted for without calling upon the aid of the vaso-motor 
nerves. While, therefore, it is probable that morphine does exert the 
influence he claims for it, the question must be still considered as sub 
judice: that the vaso-motor system is not paralyzed even in extremis 
is shown by Gscheidlen’s experiment ( loc. cit ., p. 52), in which electrical 
stimulation of the cord at such time induced immediate rise of the 
arterial pressure. The action of morphine upon the brain is certainly 
independent of any action on the vessels.* 

Action on the Respiration. —Death occurs from opium, in the great 
majority of cases, by failure of the respiration ; and that such failure is 
due to a direct action of the poison upon the respiratory centres in the 
medulla is proved by the fact that morphine affects the breathing of 
dogs and rabbits whose pneumogastrics have been cut, as much as it 
does those whose nerves are entire (Gscheidlen, loc. cit ., p. 64). 

The action of opium or morphine upon the elimination of carbonic 
acid has been studied by Boeck and Bauer (Zeitschr. f. Biolog., x. 339) 
and by Messrs. Chittenden and Cummins ( Laboratory of Physiological 
Chemistry , Yale University , vol. ii.). Their results are concordant in 
showing that the effect of the alkaloid upon carbonic acid production 
is in direct relation to its influence upon the muscular system. The 
elimination is increased when convulsions occur, but decreased when 
narcotic quietude is produced. 

Action on the Pupil. —Since morphine locally applied does not affect the 


* Consult Binz, Arch./. E-rper. Pathol, und Pharm., vi. 310 ; Vulpian, Lemons sur I’Appar. 
vaso-moteur, ii. 156. 



SOMNIFA CIENTS. 


163 


pupil, it follows that its constitutional action upon the latter is through 
the nerve-centres. It is probable, but has not, that I am aware of, been 
experimentally proved, that the contraction of the pupil is due to a 
stimulation of the oculo-motor nerve-centres, and that the dilatation 
of the pupil as death approaches is due to a paralysis of the same. 
Indeed, it cannot well be otherwise; for if the primary contraction 
were due to paralysis of the sympathetic, the secondary wide dilatation 
would be impossible; the dilating force— i.e., the sympathetic—having 
been withdrawn, the pupil would not widely expand even if the con¬ 
tracting force— i.e., the oculo-motor—were paralyzed. 

In birds (Dr. S. Weir Mitchell, loc. cit.) the pupil is not affected; in 
horses it is widely dilated (Dr. Harley, loc. cit.) ; and in dogs it dilates 
before contracting (Dr. Eeese, loc. cit., apparently confirmed by Exper¬ 
iment number eight, Harley, loc. cit., p. 109), or sometimes remains 
unchanged (Harley, loc. cit., p. 111). At present these anomalies cannot 
be explained. 

Eliminative Action on the Kidneys and Intestines. —The exact fate of 
morphine in the system is uncertain. Various chemists have failed to 
find it in the urine of persons or animals poisoned by it, but it seems 
to me established that it is at least in part eliminated with that secre¬ 
tion, as it has been detected by Dr. Hilger (Gscheidlen, loc. cit., p. 32), 
Bouchardat ( Schmidt's Jahrbucher, Bd. cxx.), Lefort ( Journ. de Chimie, 
Bd. xi.), Kausmann ( Inaug. Dissert., Dorpat, 1868), and Kratter ( Vir¬ 
chow's Jahrb., 1882). Although Professor Wormley ( Micro-Chemistry, 
p. 503) states that the tests relied upon by Bouchardat ax*e not decisive, 
it is probable that the conclusions reached in the elaborate research of 
W. Eliasson are correct ( Inaug. Dissert., Konigsberg, 1882). They are, 
that when large amounts are invested morphine appears freely in the 
urine, but that after small doses it cannot be found, although a sub¬ 
stance is present giving some of the reactions of morphine, from 
which it is a derivative. The theory that morphine is burnt up in the 
blood has been advocated by those who have failed to find it in the 
urine (see E. Landsberg, Pfluger's Archiv, 1880, p. 413; also Julius 
Donath, Ibid., 1886, p. 528) and there is reason for believing that it 
and other alkaloids are to some extent destroyed in the liver. The 
amount of the urinary secretion is said to be sometimes increased by 
morphine; but generally it is diminished. Betention, which after 
a full dose of opium is not rare, depends upon the blunting of the 
sensibility of the bladder. In a series of examinations S. Fubini 
found that morphine, codeine, narceine, narcotine, and thebaine each 
increase the excretion of urea in man: upon the lower animals their 
action seemed to vary greatly ( Hoffmann und Schwalbe Jahresber., 1883, 
p. 219). It is stated that in abitual opium-eaters morphine occurs in 
the urine not longer than seven days after the cessation of the habit 
(Loud. Med. Record, 1877, p. 92). 

Peristaltic movements, according to the experiments of Professor 


164 


GENERAL REMEDIES. 


Nothnagel ( Archiv f. Path. Anat ., lxxxix. 2), confirmed by J. Ott 
(. N . Y. 3fed. Journ ., 1883), are diminished by small doses of morphine, 
but increased by toxic doses. The first effect is evidently due to stimu¬ 
lation of the inhibitory nervous apparatus, and the second to paralysis 
of the same: it is probable that it is the centre that is affected. The 
experiment which Professor Nothnagel brings forward as evincing a 
peripheral action is certainly not pertinent. 

Upon the digestive tract opium exerts a very marked influence, 
checking secretion and causing constipation, acting in these respects 
more efficiently than does morphine.* 

Therapeutics. —The chief indications for the use of opium are 
considered below, seriatim. Nearly all of them flow evidently from the 
known physiological action of the drug; others, however, although 
established by clinical experience, and undeniable, are not so plain in 
their philosophy. 

1. To relieve pain. As an analgesic, opium is without a rival in the 
materia medica, except it be the anaesthetics. It is used to allay pain 
arising from any cause whatever, except acute inflammation of the 
brain, and is preferred to the anaesthetics whenever the pain has any 
permanency. In painful spasm it is especially useful, as it seems very 
frequently to quiet the motor as well as the sensory disturbance. 

2. To produce sleep. Sleeplessness occurring in acute disease, and 
not dependent upon cerebral inflammation, may very frequently be re¬ 
lieved by opium. While it is often necessary to use the drug freely in 
such affections as delirium tremens , care should be exercised not to over¬ 
whelm the nerve-centres by enormous doses. In habitual sleeplessness 
great caution must be used in the employment of opium, not so much 
on account of the disturbance of digestion which it is liable to cause, 
as for fear of producing the “ opium habit.” Chloral is perhaps a more 
generally applicable hypnotic than opium. Bo this, however, as it may, 
I have found the combination of morphine and chloral singularly effi¬ 
cient. In low fevers, adynamic delirium often coexists with sleepless¬ 
ness, and is then best met by opium. 

3. To allay irritation. In various forms of nervous erethism, opium 
is most valuable; but when the affection is at all chronic, the dangers 
of the opium habit should not be lost sight of. On the other hand, in 
acute cases, as in the excitement which so frequently attends hcemoptysis, 

4 

* The exercise of function is, no doubt, always dependent upon or connected with nutri¬ 
tive movements in the part. Without question, any poison which produces functional excite¬ 
ment affects the nutrition of the excited part. But this alteration of nutrition must rarely 
progress far enough to be recognizable by the microscope. Various pathologists have studied 
the condition of the spinal cord and other nerve-centres after poisoning by different toxic 
agents, and some believe that even after the use of morphine, bromide of potassium, and 
similar substances, distinct changes in the ganglionic nerve-cells are to be made out, while 
others have failed to detect these changes. For recent papers on the subject consult W. V. 
Tschisch ( Virchow’s Arcliiv, 1885, Bd. c. 147), and Dr. F. Kreyssig ( Virchow’s Archiv, 1885, 
Bd. cii. 287). 



SOMXI FA Cl ENTS. 


165 


the drug should be used freely. In many cases of disease, opium is 
serviceable by sustaining the system against an irritation for the time 
being irremediable, by blunting the sensibilities. In this way it is use¬ 
ful iu the advanced stages of smallpox , and in various surgical affections, 
in which it also does good by allaying pain. In various local irritations 
opium is continually employed, as in colic caused by undigested food, 
and in bronchitis to quiet cough. 

By allaying irritation and pain, opium affords relief in most cases 
of inflammation; but in certain varieties of the affection it seems to do 
much more than this, exerting, in some way at present difficult to ex¬ 
plain, a life-saving influence. In peritonitis , after due depletion, or in 
cases not requiring depletion, it should always be exhibited in large 
doses at regular intervals, in such a way as to keep the patient in a 
state of decided narcotism. 

In severe acute vomiting , opium is one of the most reliable remedies. 
It is best used in the form of suppositories. Although, by checking 
secretion and peristalsis, opium usually causes constipation, yet when 
obstruction of the bowels is produced by spasm due to an irritation or 
inflammation, by relieving the latter the drug will sometimes act as a 
most efficient laxative. 

4. To check excessive secretion. For this purpose opium is very largely 
employed in diarrhoeas , and is very efficient either alone or in combi¬ 
nation with various remedies. In enteritis and in dysentery , although 
no less frequently used than in diarrhoea, it is of service rather as an 
antiphlogistic and analgesic than by checking secretion. In diabetes 
insipidus, the combination of it and gallic acid is, I think, the most 
generally successful remedy. 

In true saccharine diabetes , opium is of very great value in many 
cases, often ameliorating the symptoms, and, in conjunction with re¬ 
stricted diet, sometimes even effecting a cure. Of course, however, 
like all other known remedies in this disease, it most frequently acts 
simply as a palliative. According to Dr. Pavey (Med. Times and Gaz., 
June, 1869), it affects the quantity of the urine before diminishing the 
sugar in it. 

In severe mercurial ptyalism, opium often seems to check the dis¬ 
charge, but certainly is not nearly so powerful in this regard as atropine. 

5. To support the system. Opium appears in low fevers, and in vari¬ 
ous protracted adynamic illnesses, to afford actual support to the system 
in some way not as yet made out. This is especially the case when, 
from any reason, sufficient food to keep up life cannot be taken or 
retained. Opium is a valuable remedy for the purpose of protracting 
and rendering more comfortable life in the aged. When the bodily 
powers are failing, and various functional disorders are from time to 
time occurring, it is often possible to check, by the use of opium, attacks 
which, if allowed to obtain headway, would extinguish the flickering 
life. Further, in many cases of feeble, very old and suffering people 


166 


GENERAL REMEDIES. 


the habitual use of opium under careful restriction by the physician is 
not only justifiable, but necessary if life is to be maintained as long as 
possible. In such persons the danger of forming an opium habit which 
shall do injury is a minimum. 

6. As a sudorific. Dr. A. Loomis (. N'. Y. Med. Record , 1873) praises 
very highly the use of hypodermic injections of morphine in acute 
urcemia. He states that the drug must be given in sufficient quantity 
to control the convulsions, which it does most happily, at the same 
time producing profuse diuresis. Dr. Morrison Fiset (JV. Y. Med. 
Record , July, 1874) and Dr. Dain ( American Med. Journ., July, 1874) 
confirm this. In some instances the remedy has seemed to act very 
happily, but in one or two cases at the Philadelphia Hospital its exhi¬ 
bition was shortly followed by death, and I think the practice is a 
dangerous one. My own belief is that whenever the kidneys are seri¬ 
ously diseased the physician should be exceedingly careful in the admin¬ 
istration of opiates, because the chief channel through which these are 
eliminated is choked up. In the form of Dover’s powder, opium is very 
largely used when it is desired to produce sweating, as in the early stages 
of a “ general cold,” or in other forms of muscular rheumatism. With its 
use should generally be conjoined such measures as “ soaking the feet,” 
covering warm in bed, and the free drinking of hot lemonade or hot 
teas. 

Toxicology.— Sufficient has already been said concerning the course 
and symptoms of poisoning by opium in ordinary cases.* Sometimes 
in adults trismus and other convulsive manifestations are added to, or 
in a measure replace, the usual phenomena, and in children the drug 
appears at times to overpower the nerve-centres at once, so that the 
second stage is very much shortened or aborted, and symptoms of col¬ 
lapse, with unconsciousness, are developed very rapidly. The positive 
diagnosis of opium-poisoning from the symptoms alone is often impos- 
sible.f In some cases of congestion of the brain, or of apoplexy, or 
of uraemia, the phenomena are identical with those sometimes seen in 
opium-poisoning. I have thought that inequality of the pupils is proof 
that a case is not one of narcotism; but Professor Taylor has recorded 
an instance of opium-poisoning in which it occurred (Medical Jurispru¬ 
dence , 7th Am. ed., 1873, p. 205). 

, The indications in the treatment of poisoning by opium are: first, 
to evacuate the stomach; second, to maintain respiration; third, to 
keep up the circulation when failing. The first indication may be met 
in two different ways: by an emetic, and by the stomach-pump or tube 
used as a siphon. There is often in narcotic poisoning great difficulty 
in getting an emetic to act, owing to the obtunding of the sensibility 


* For discussion of effect on nursling and foetus when morphine is given to the mother, 
see Amer. Journ. Obst., 1877. 

f See Philadelphia Med. Times, iii. 593; also Dr. Wilks, Med. Times and Gaz., 1863. 



SOMNIFA Cl ENTS. 


167 


of the nervous system by the drug. For this and other reasons, so 
palpable as not to need mentioning, a prompt stimulant emetic should 
be used. Antimony, on account of its depressing influence, should al¬ 
ways be avoided. Mustard flour is almost always to be had at once, 
and is very efficient. A heaped tablespoonful stirred up in a tumbler¬ 
ful of warm water should be exhibited as soon as possible, and, if it 
fails to act in fifteen minutes, should be repeated; then a powder of 
thirty grains each of sulphate of zinc and ipecacuanha may be given, 
to be repeated once or twice, at intervals of fifteen or twenty minutes. 
Large draughts of warm water should be administered in the inter¬ 
vals, and also between the acts of vomiting, so as thoroughly to wash 
out the stomach. The stomach-pump* is of no value when the solid 
drug has been ingested, but, if at hand, is preferable to emetics when a 
fluid preparation has been taken, because of the promptness of its 
results. 

To maintain respiration is the ultimate object of all the measures 
which are commonly undertaken for the purpose of arousing the system 
in opium-poisoning. Unconsciousness in itself is of no moment, but as 
it deepens the sensibility of the respiratory centres grows less, and con¬ 
sequently the involuntary breathing is less rapidly or less perfectly per¬ 
formed. More than this, when at all awake, a patient suffering from 
opium-poisoning can be made to supplement the almost suspended auto¬ 
matic breathing by voluntary respiration ; and every effort to induce him 
to do this should be used. It is often surprising how an apparently un¬ 
conscious man can be made to breathe by a command shouted in his ear. 
To keep a patient awake, walking, flagellations with small, fine twigs, 
shaking, shouting, and various other methods which may suggest them¬ 
selves, should be practised. Care should always be exercised not to 
carry these useful measures unnecessarily far, and perhaps add physi¬ 
cal exhaustion to the natural prostration of the third stage. I desire 
also to call especial attention to strong faradic currents as a means of 
causing pain, and therefore of rousing the patient, without leaving the 
bruises and soreness which often result from the severe flao-ellations 

o 

practised. 

The cold douche affords an excellent method of rousing the patient 
and at the same time of especially stimulating respiration. The sim¬ 
plest method of application is to support the head and shoulders of a 
patient stripped to the waist over a common wash-tub, and to dash the 


The siphon stomach-pump may be extemporized by any one. It consists simply of an 
india-rubber tube three and a half to four and a half feet in length, of proper calibre, which 
is passed into the stomach. The external end being elevated, water is poured into it until 
the stomach is full; then, without the tube being allowed to empty itself, the external end is 
dropped, when, of course, the flow of water is reversed. 

f Various drugs have been stated to be antagonistic to opium and cases of recovery re¬ 
ported: Veratrum Viride, Cincinnati Lancet and Clinic, 1879, iii. 458; St. Louis Med. and 
Surg. Journ., 1879, xxxvii. 601; Aconite, New York Med. Record, 1880, viii. 



168 


GENERAL REMEDIES. 


water over the chest and head. The effect is much greater if ice-cold 
water and water a little hotter than the hand will bear (115° F.) be 
used in quick succession. In the way of drugs, there are only three 
substances worthy of mention. Very strong infusions of coffee or of 
green tea have been long used in opium-poisoning, and recent scientific 
studies (Brit. Med. Journ., 1874, ii. 698, 699) have shown that in animals 
doses of morphine otherwise lethal may be successfully combated by 
theine or caffeine; atropine, as a respiratory stimulant, is of the greatest 
value in opium-poisoning when there is evident failure of respiration 
(for discussion of its use, see the article on Atropine); and alcohol is to 
be employed in the stage of depression to sustain the arterial system.-}* 
If the bodily temperature falls, it must be maintained by the free use of 
external heat. It is interesting here to note that Drs. Lauder Brunton 
and Cash found that the fall which occurs both in the bird and in the 
mammal is not prevented by placing the animal in a temperature just 
below that of the body. 

Whenever life is in evident danger from the insufficiency of natural 
respiration, the use of artificial respiration should not be postponed, but 
should be practised to supplement nature, and should be maintained 
so long as there is any hope. Life has undoubtedly been saved in this 
way. A case is reported (iV. Y. Med. Journ., June, 1880) in which a 
baby who had taken one-third grain of morphine was rescued by arti¬ 
ficial respiration kept up, off and on, for twenty-four hours. In some 
cases excess of bronchial mucus seems to be of serious import. Under 
such circumstances good might be achieved by placing the patient in 
an inverted position (Brit. Med. Journ., 1871, ii. 374). 

Opium-poisoning usually has no sequel®; but a case in which amau¬ 
rosis was produced is reported in Schmidt's Jahrbucher, Bd. clvii. p. 74, 
and glycosuria is said to have followed the poisoning (La France Med., 
1883, ii.). 

In regard to the amount of opium which will cause death, the 
smallest fatal dose on record is one-sixth of a grain of morphine in 
the adult (Dr. Buskirk, Washington Post, Jan. 30, 1878).* According 
to Dr. A. Calkins (Quart. Journ. Psycholog. Med., 1868, ii. 739), four 
grainsf of crude opium placed in the ear have caused death; also four 
grains by the mouth in more than one case. According to the author¬ 
ity just quoted, out of twenty-nine reported cases in which a fluid- 
ounce of laudanum was taken, nine died. The maximum doses from 
which recovery has occurred without emesis are fifty-five grains of the 
solid opium and six ounces of laudanum. In a babe a day old, one 
minim of laudanum (E. Smith, Lancet, 1854), and in one aged nine 

* A number of cases are now on record in which death has been produced in the adult by 
the hypodermic use of from one-sixth to one-half grain of morphine. Consult Med.-Chir. 
Trans., vol. i.; Chicago Med. Examiner, May, 1878; Quart. Journ. Psycholog. Med., 1868, 
ii. 739. 

f Taken from Journal de Chimie, 1831. Assuredly there is a mistake in this case. 



SOMNIFA Cl ENTS. 


169 


months, a few drops of paregoric (Wood, Bost. Med. Surg. Jonrn., 1858), 
have proved fatal. Death of an adult female has been attributed, with 
doubtful accuracy, to thirty grains of Dover’s powder, given in divided 
doses ( Chicago Med. Journ. and Exam ., July, 1882), and still more 
hypothetically to a quarter of a grain of morphine ( Boston Med. Surg. 
Journ., Jan. 3, 1885). Recovery is asserted to have occurred after the 
ingestion of eighteen grains of morphine without vomiting (Dr. Wm. 
C. Chaffee, Med. Surg. Rep., 1882, xlvii. 697). 

For full details as to the results of the habitual use of opium or its 
alkaloid, the reader is referred to the treatise of Dr. Albrecht Erlen- 
meyer ( Die Morphiumsucht). No confidence can be placed in the state¬ 
ments of the opium-eater, and it is essential for cure that such person 
be in a hospital or be confined to an apartment under the care of an 
absolutely reliable nurse, so that the orders of the physician can be 
strictly enforced. The basis of the treatment must consist in the 
withdrawal of the narcotic, and there are three distinct ways in which 
this can be effected. First, the opium may be suddenly taken away; 
secondly, it may be taken away rapidly, but not suddenly; thirdly, it 
may be withdrawn very gradually. The first of these methods is un¬ 
doubtedly in most cases efficient, but is often attended with grave 
danger of collapse, and has no distinct advantages over the plan of 
rapid withdrawal. The time required for the very gradual withdrawal 
of the remedy is too great for practical purposes, and the sufferings of 
the patient are too long drawn out. Unless the daily dose has been 
extraordinary or the patient is in a very feeble condition, it is entirely 
safe to withdraw the narcotic entirely in from seven to twelve days. 
An excellent plan is to direct that a solution of morphine or opium be 
prepared, and whenever a dose is taken out an equivalent amount of 
water be added. The chief symptoms that follow the rapid -withdrawal 
are excessive malaise, insomnia, complete loss of appetite, vomiting, 
diarrhoea, and great feebleness. I have never yet seen a ease in which 
these symptoms were so uncontrollable as really to cause alarm for the 
safety of the patient. Much may be done by proper feeding. The food 
should consist of highly nutritious, stimulating, and easily-digested 
articles, and in severe cases should be liquid, such as milk, rich soups, 
etc. When the circulation fails, alcohol may be used, and much relief 
may be afforded by massage, and often by simple rubbing of the patient. 
General electrical stimulation and faradization of the muscles is often 
useful, not only by its effect upon the circulation, but also by distracting 
the attention of the patient from his sufferings. The use of the alkaloid 
cocaine as a stimulant has been recommended. I have seen apparently 
very good results from the free internal administration of the fluid ex¬ 
tract of coca, but I do not think that the use of hypodermic injec¬ 
tions of cocaine is justifiable, as the danger of setting up the cocaine 
habit is too great. If gastro-intestinal irritation exists, bismuth may 
be administered freely. The diarrhoea is usually controllable by mild 


170 


GENERAL REMEDIES. 


astringents, especially if combined with sulphuric acid. If the bodily 
temperature falls at all, it must be maintained by external warmth. The 
bromide of potassium, valerianate of ammonium, Hoffman’s anodyne, 
and other similar feeble nerve-sedatives may be employed and give 
some comfort. Moral support and stimulation are essential, and any 
device which aids in passing the time of suffering is most beneficial. 

Administration.— When it is desired to produce very decided 
narcotism by the use of repeated doses of opium, the drug should 
always be given in liquid form , since opium pills sometimes become 
very hard and undergo solution so slowly that they may accumulate 
in the alimentary canal. On the other hand, in diarrhoeas, or in sick¬ 
ness of the stomach, old opium pills are thought by some to act better 
than do more soluble forms of the drug. 

Many persons cannot take opium on account of the very great 
secondary nausea and depression which it produces. It has been sup¬ 
posed that these disagreeable after-effects are due to the narcotine in 
opium; but this can hardly be, seeing that they often follow the use of 
the pure alkaloid, morphine. The deodorized tincture of opium agrees 
with some individuals better than any other preparation of the drug; 
and, as first pointed out by Dr. Da Costa, by giving a drachm of the 
bromide of potassium with twenty-five drops of it, the after-effects of 
the narcotic are often entirely avoided. In many neuralgic women the 
knowledge of this fact is an inestimable boon; in others the unpleasant 
symptoms are not averted by the bromide. 

Children always bear opium very badly, and to them only the 
weaker liquid preparations should be given. Dover’s powder should 
especially be avoided. It is probable that in its manufacture on the 
large scale the ingredients are sometimes not thoroughly mixed: at 
least I have seen cases in which the symptoms caused by it were seem¬ 
ingly so out of proportion to the dose as to suggest that more than the 
officinal amount of opium was present. 

In acute vomiting from any cause, in dysentery , in strangury and 
other irritations of the urino-genital organs, great advantage is often 
to be gained from the use of opium by the rectum. Suppositories 
made out of the extract (gr. ss to i), or enemata of laudanum (gtt. xxx 
to xl), may be used in these cases. The latter should be made b} r add¬ 
ing the narcotic to a tablespoonful of starch-water. 

The dose of opium for an adult is from one to two grains; for a 
child a year old, one-twenty-fourth of a grain. The TJ.S. Pharmaco¬ 
poeia directs that opium in its normal moist condition should contain 
not less than nine per cent, of morphine, and that dried powdered opium 
(Opii Pulvis , U.S.), out of which the preparations are made, should con¬ 
tain from twelve to sixteen per cent, of the alkaloid. 

The solid officinal preparations of opium are—the denarcotised 
opium (Opium Denarcotisatum, U.S.), opium deprived by the action of 
ether of its narcotine, dose, one to two grains; pills of opium (Pilulce 


SOMNIFACIENTS. 


171 


Opii, U.S.), containing one grain each; watery extract (Extract-urn 
Opii, TJ.S.), twice the strength of opium. 

Paregoric (Tinctura Opii Camphor at a, U.S.) has in every fluidounce 
two grains of opium, besides benzoic acid, oil of anise, and camphor, 
and, in consequence of the last ingredient, is more constipating than 
the other preparations of opium, and hence is preferred in diarrhoea- 
mixtures. It is also much used in cough-mixtures. Dose, fji to f£i. 
The other liquid preparations all now represent ten per cent, of pow¬ 
dered opium by weight, and may be given in doses of ten to fifteen 
minims. The deodorized tincture (Tinctura Opii Deodorata, U.S.) con¬ 
tains no narcotina, and none of the odorous principle of opium. It 
therefore is less apt to cause nausea than are the other preparations. 
Its drop almost equals the minim in size. The other preparations are— 
Tinctura Opii , U.S., or Laudanum (one hundred drops to the fluidrachm); 
Tinctura Opii Acetata, U.S., or Acetated Tincture (formerly gr. xlviii to 
foi) 5 Vinum Opii, U.S., or Sydenham's Laudanum (formerly Ji to fji) ; 
Acetum Opii, U.S., or Black Drop (formerly gr. lxxv to f3i). 

MORPHINA* U.S. 

This alkaloid occurs in minute, colorless, shining crystals, according 
to Guy melting at 330° F. and subliming at 340° F.; insoluble in cold 
and nearly so in boiling water; only slightly soluble in cold alcohol 
and ether; freely soluble in boiling alcohol and in the fixed and vola¬ 
tile oils. 

The following are some of the most sensitive and characteristic 
tests. In a solution of the alkaloid in concentrated sulphuric acid, 
which has been allowed to stand from ten to twelve hours, or has been 
heated for half an hour to 100° C. or momentarily to 150° C. and 
allowed to cool, the faint-reddish violet changes at the point of con¬ 
tact to a deep-blue violet upon the addition of dilute nitric acid or of 
a crystal of saltpetre. Morphine with concentrated sulphuric acid 
makes a colorless solution, which on strong heating becomes red, violet, 
dirty green. With concentrated nitric acid it makes a red color, and 
finally a yellowish solution. With the neutral chloride of iron mor¬ 
phine strikes a blue color, perceptible only when the test contains one 
part of the alkaloid in six hundred. Less characteristic, but much 
more sensitive, is the iodine test, with which, according to Husemann, 
one-ten-thousandth part of morphine can be recognized. Iodic acid, 
in the form of a mixture of iodate of potassium and sulphuric acid, is 
to be added to the suspected solution. If morphine be present, iodine 
will be set free, and can be recognized by the starch test. 

The Acetate (Morphince Acetas ), Sulphate (Morphince Sulphas ), and 
Hydro chlorate or Muriate of Morphine ( Morphince Hydrochloras ) are 
all officinal. The first is a white powder; the last two occur snow- 


* For spectrum analysis of morphine, see New York Medical Journal, 1874. 



172 


GENERAL REMEDIES. 


white in feathery crystals. They are all soluble in water, and are of a 
bitter taste. 

Therapeutics. —The salts of morphine differ in their therapeutic 
value from opium chiefly in that they act with less power as sudorifics 
and in checking secretion in the bowels, and consequently are less con¬ 
stipating. The smallness of their dose and their perfect solubility fit 
them for hypodermic use. Almost the only purpose for which they are 
used in this way is to relieve pain. The advantages of the method are 
the quickness of the results and the increased power of relieving suffer¬ 
ing which the remedy seems to acquire. In cases of severe pain, hypo¬ 
dermics are invaluable; but it must be borne in mind that sometimes 
they cause most unpleasant symptoms. I have seen very alarming 
results from the injection of one-sixth of a grain, and half a grain has 
produced death. In females, unless very robust, the maximum dose 
should be one-eighth of a grain; in men, one-sixth to one-quarter. The 
dose of a salt of morphine corresponding to a grain of opium is one- 
quarter of a grain. The dose of the formerly officinal solution ( Liquor 
Morphince Sulphatis, TJ.S. 1870,—gr. i to f^i) is one to three drachms. 
Magendie's Solution of Morphine contains sixteen grains to the fluid- 
ounce : it is not officinal, and should not be kept in the apothecaries’ 
shops. The Suppositories (Suppositoria Morphince , TJ.S.) contain each 
half a grain of morphine. 

NARCEINA. 

This alkaloid, which is not officinal, was discovered by Pelletier in 
1832. “ It crystallizes out of its watery, alcoholic, and dilute acid solu¬ 

tions in long, white, four-sided, rhombic prisms, or in bunched masses of 
fine acicular crystals, odorless, and of a taste at first bitterish, but later 
styptic.” (Pelletier, Hesse, Winckler—Husemann, Die Pflanzenstojfe.) 
According to Pelletier, it is soluble in 375 parts of water at 13° C.; 
according to Hesse, in 1285 parts at 12° C.; while Dr. S. Weir Mitchell 
found that a specimen prepared by Merck dissolved in 1000 parts, one 
prepared by Powers & Weightman in 4000 parts, one of unknown 
European manufacture in 2100 parts, of distilled water at 60° F. Its 
saturated solution in boiling water on cooling fills with crystals. Con¬ 
centrated nitric acid dissolves narceine with a yellow color, and the 
solution on being heated gives off reddish fumes; iodine makes with it 
a bluish-black mass, which forms a colorless solution in boiling water, 
but on cooling separates; with concentrated sulphuric acid narceine 
strikes a brown color, and finally makes a clear yellow solution (Huse¬ 
mann). 

Physiological Action. —According to Baxt ( Reichert's Archiv, 1869, 
p. 126), three or four centigrammes (0.46 to 0.62 gr.) of narceine, when 
injected into a frog, produce, in from ten to fifteen minutes, a semi- 
comatose condition, in which the batrachian makes no resistance or 
effort when laid upon his back or in other unnatural position. The 


SOMNIFA Cl ENTS. 


173 


respiration and circulation are not disturbed. The frog can be aroused 
by strong irritation, and when awake seems perfectly conscious. In 
three to six hours he comes out of his lethargic condition apparently 
unatfected. Albers ( Virchaw's Archiv, vol. xxvi.) found that one grain 
produces in the frog sleep, reflex and spontaneous convulsions, and, 
after seventy-four hours, death. According to Ott, the convulsions are 
chiefly spinal, the muscles also being affected. Dr. S. Weir Mitchell 
(• Amer. Journ. Med. Sci., Jan. 1870) found nine grains of the alkaloid to 
have very little effect upon pigeons, causing only abnormal quietness. In 
Baxt’s experiments upon rabbits and guinea-pigs, fifteen centigrammes 
(2.3 gr.) had no perceptible influence; and on dogs Dr. S. Kersch 
( Schmidt's Jahrbucher, Bd. cxli. p. 15), and also Dr. Harley ( The Old 
Vegetable Neurotics , p. 143), found moderate doses (26 ctgr., Kersch) 
equally inert. In a mouse (Harley) one-half grain caused tranquil 
sleep, with, after a time, tremors, from which the animal recovered, to 
be taken suddenly, some hours later, with fatal convulsions. At the 
post-mortem the tubules of the kidneys were found completely choked 
up with the alkaloid, which had crystallized in them and produced a 
mechanical suppression of urine, to which death was probably due. 
Schroff (quoted by Rabuteau), Fronmuller ( Schmidt’s Jahrbucher , Bd. 
cxli. p. 15), Harley, Mitchell, and Da Costa (. Pennsylvania Hospital Re¬ 
ports, 1868), have found narceine to act very feebly upon man. Harley 
gave one grain hypodermically, Da Costa two and one-half grains by 
the mouth, and Mitchell took five grains himself, with the result of 
only causing some headache; and Fronmuller has exhibited as much 
as twenty grains with equally negative results. 

These investigations are in close concord, and seemingly conclusive; 
and the study of Dr. Da Costa upon man was very full and exhaustive. 
They are opposed by a number of seemingly equally conclusive investi¬ 
gations made by various French and German observers. Much of the 
interest that has been manifested in the alkaloid arose from the asser¬ 
tion of Claude Bernard in 1864 ( Archives Generates , 6e ser., t. iv. p. 
459) that it is the most pleasant and certain hypnotic of any of the 
opium alkaloids. He experimented upon dogs, guinea-pigs, rats, pigeons, 
sparrows, and frogs, and in all of them there was produced deep sleep, 
closely resembling natural sleep, with benumbed but not destroyed sen¬ 
sibility. The irritability of the morphine-sleep was wanting, and no 
secondary depression followed. Seven to eight centigrammes (0.8 to 1.2 
gr.) was sufficient to throw a dog into the profoundest slumber. As 
early as 1852, Lecomte (Husemann, Die Pflanzenstoffe, p. 176) had 
affirmed that 0.1 grm. (1.53 gr.) of narceine thrown into the jugular 
vein of a dog would produce deep sleep, and very recently Rabuteau 
has confirmed the results of Bernard. Further, Behier (Bull. Therap., 
t. lxvii.), Debout (Ibid.), A. Eulenberg (Schmidt’s Jahrbucher, Aug. and 
Oct. 1866), and Line (Journ. de Pharm. et de Chun., 4e ser., t. iii.) also 
assert as the result of experience that narceine, in doses of one-half 


174 


GENERAL REMEDIES. 


grain to a grain, produces in man pleasant, persistent sleep. Rabuteau 
(loc. cit.) also agrees with this, except in placing the dose somewhat 
higher,—viz., at from ten to twenty centigrammes (1.53 to 3.06 gr.). 
Oetinger (Das Narcein, Diss. Inaug., Tubingen, 1866) also asserts that 
decidedly larger doses of narceine than of morphine are required to 
obtain any action. 

As seemingly these opposing results are all true, the only possible 
explanation is that different substances were used by the different sets 
of observers under the one name. As the greatest care was practised 
by Harley and Mitchell in obtaining the alkaloid pure, and as Claude 
Bernard states expressly that the substance used by him was soluble 
in twenty parts of water, it is probable that the former observers 
really had, and that Bernard did not have, the narceine of Pelletier. 

It is, at any rate, a very plain deduction from the above facts that 
if it be so difficult—nay, impossible—to obtain in commerce a uniform 
reliable narceine, it is not proper to use it as a medicine. 

CODEINA. U.S. 

Albers found that one grain of the muriate of codeine would produce 
in the frog, twenty minutes after its injection, tetanic cramps, alter¬ 
nating with convulsions, evidently reflex, since the slightest touch would 
call them forth. After a time the convulsive excitement grew less and 
less; the fore feet lost their sensitiveness first, but finally a paroxysm 
could no longer be provoked by touching the hind feet. The pupils at 
this time were widely dilated. Death occurred by failure of respira¬ 
tion, the heart continuing to beat a quarter of an hour after the ex¬ 
tinguishment of all other movements. In Woldemar Baxt’s ( Reichert's 
Archiv, 1869, p. 125) experiments, three centigrammes (.045 gr.) pro¬ 
duced in the frog deep sleep, lasting three or four hours. On awaking, 
the frog seemed more sensitive than natural to external irritation. Six 
centigrammes produced sleep more quickly, and following the deep 
sleep a stage of excessive sensitiveness, during which external irritation 
produced repeated cramp-like contractions. M. Wadis (quoted by 
Husemann, Die Pflanzenstoffc, p. 163) observed phenomena similar to 
those detailed by Albers, but noted a peculiarit}^ of gait in the frog 
preceding the convulsive stage, owing apparently to disturbance in the 
innervation of the adductors. Wachs also found that .01 gramme 
(0.15 gr.) produced in the pigeon only increased rate of respiration 
and sleepiness, while larger fatal doses caused restlessness, inability to 
stand, movements backward and in a circle, disturbance of respiration 
with gasping, cramps of single muscles, and finally convulsions, mostly 
clonic, frequently repeated, and followed by an adynamic condition, 
terminated by sudden death. In Dr. S. Weir Mitchell’s experiments 
(Amer. Journ. Med. Sci., Jan. 1870, p. 26), seven grains produced violent 
non-tetanic convulsions, ending fatally in one minute, and one grain 
caused sifhilar symptoms, terminating fatally in eight minutes. Dr. 


SOMNIFACIENTS. 175 

Ott ( Opium, Alkaloids ) found that the convulsions in the frog are spinal, 
but that the muscles are affected. 

According to Husemann (loc. cit., p. 133), Kunkel, in 1833, from his 
experiments arrived at results similar to the recent ones of Bernard. 
The latter observer found that five centigrammes (.075 gr.) produced 
in dogs a sleep similar to, but not so profound as, that of morphine, 
with less benumbing of sensation, and not followed by any symptoms 
of depression. 

These results have been called in question by ITarley, and it seems 
most probable that Claude Bernard used something more than codeine 
in his experiments. Certainly Harley found that one to two grains of 
the alkaloid produced in the dog disturbance of respiration, languor, 
and convulsive twitchings, but no sleep. Moreover, Husemann states 
that, after fatal doses, Wachs observed similar symptoms in the dog 
and in the rabbit, as follows: falling of the head, trembling, spasmodic 
movements of the eyes and lips, rarely trismus, movements in a circle 
and backwards, weakness of the legs, with hurried respiration and 
prominence of the eyeballs as prodromes; later in the poisoning there 
were severe convulsions, after one or many paroxysms of which great 
weakness developed, ending in death. Barnay, in experiments upon 
dogs, cats, and rabbits, found that the convulsions were the most promi¬ 
nent symptom (He la Codeine , Paris, 1877). Falck affirms (Deutsche 
Klinik , 1870) that there are two forms of poisoning produced by codeine, 
—the one tetanic and the other soporific,—corresponding apparently to 
the different results of various observers.* 

As a hypnotic in man, codeine has been used by Magendie, Berthe, 
Aran, Krebel, Reissner, Robiquet, and others, some of whom assert that 
the sleep produced by it is followed by nausea or other symptoms of 
depression, while others deny this. It does not seem necessary to dis¬ 
cuss in detail the researches of the authorities quoted, but it may be 
well to give the results of one or two of these observers more in full. 

Robiquet in a series of experiments found that doses of 0.01 to 0.03 
gramme (.15 to .46 gr.) produced a feeling of contentment, calmed ner¬ 
vousness, and induced refreshing sleep, while 0.1 to 0.2 gramme (1.53 
to 3.07 gr.) caused deej> sleep, followed by nausea and vomiting; 0.1 
gramme (1.53 gr.) caused in children very alarming symptoms. Har¬ 
ley has found in a number of experiments that, given by the mouth, 
codeine is a very uncertain and feeble hypnotic, four grains producing 
simply accelerated pulse, contracted pupils, and some giddiness, followed 
by nausea and vomiting. When the drug is given subcutaneously, “som¬ 
nolency,” he states, “ is a more prominent effect, but only occurs in cer¬ 
tain individuals.” His hypodermic dose is one to two grains. On the 


* From what he says on p. 226, it is probable that Falck used two preparations of codeine, 
—one made in his own laboratory, the other obtained from Merck. It is not possible to 
determine from his text whether this had anything to do with the different results he obtained. 



176 


GENERAL REMEDIES. 


other hand, Dnorzak and Heinrich found that codeine in doses of 0.1 
gramme caused gastric uneasiness and pain, some salivation, nausea, 
heat, and feeling of weight in the head, some confusion of thought, 
very marked reduction of the pulse-rate, and very marked tremors 
affecting the whole body; and Mitchell took five grains of the alkaloid 
without inducing other effects than a rise of twenty per minute in the 
pulse-rate, nausea, slight giddiness, and a sense of heaviness about the 
head. Dr. A. S. Myrtle records (Brit. Med. Journ ., 1874, i. 478) a case 
of severe poisoning by four grains of codeine prepared by the Messrs. 
Smith of Edinburgh. There was first vascular excitement and exhil¬ 
aration, then depression with great anxiety, nausea and vomiting, pale, 
cool, clammy skin, slight contraction of pupil, and sleeplessness, with 
slight delirium. 

It is very evident that these various observers have not had the 
same principle. In my own experience codeine, prepared by Powers & 
Weightman, has failed to act in grain doses as a hypnotic. There are 
no reasons for believing that it has any advantage over morphine, while 
its uncertainty is very great. I have found it of some value in half¬ 
grain doses in quieting bronchial irritation. 

The remaining active principles of opium being objects of physio¬ 
logical rather than of clinical interest, I shall discuss their physio¬ 
logical actions alone. 

Narcotine .—Although in Dr. Albers’s experiment (loc. cit ., p. 244) 
one grain of narcotine proved fatal to a frog without the production 
of convulsions, yet the united testimony of Claude Bernard (loc. cit., p. 
462), of Baxt (loc. cit., p. 124), of Babuteau (loc. cit., p. 266), of Mitchell 
(loc. cit., p. 23), and of Ott (loc. cit.') shows that in the lower animals 
this alkaloid produces, when given in sufficiently large dose, active 
spinal convulsions. In small dose (one-half grain) it causes, according 
to Albers and to Baxt, in frogs a semi-comatose state. In larger dose 
(1.2 grains) the last observer found it to induce in the same batrachian 
very decided convulsions, similar to those of morphine-poisoning. Dr. 
Mitchell states that from two to three grains produce violent and fatal 
convulsions in the pigeon. Claude Bernard ranks narcotine above 
morphine and codeine, next to papaverine, as a convulsant in the lower 
animals. Yet Orfila found thirty grains necessary to kill a dog, and 
Baxt has given about two grains to rabbits and to guinea-pigs without 
producing any symptoms. 

Man is no more sensitive to narcotine than are the lower animals, 
if indeed he be as sensitive. Twenty and thirty grains of it have 
frequently been taken without effect, and doses of one hundred and 
twenty grains are said to have been exhibited with no greater result. 

Thebaine , or Par amorplxine.— Magendie, Orfila, Albers, Baxt, Claude 
Bernard, F. W. Muller (Das Thebaia, Diss. Inaug., Marburg, 1868), 


SOM XI FA Cl ENTS. 


177 


Harley, Fraser, Mitchell, Rabuteau, and other observers, all agree as 
to the very great similarity between the action of thebaine and that of 
strychnine. Falck ( Deutsche Klinik , 1869) divided the general symp¬ 
toms produced by the poison in mammals into three stages: the pro¬ 
dromal period, in which there was restlessness, combined with a desire 
to creep into corners, urination, increased frequency of respiration, and 
some stiffness of the leg; the second stage, in which there were violent 
strychnic convulsions, greatly interfering with respiration, and some¬ 
times producing cyanosis ; and the third period, in which there was para¬ 
lytic muscular weakness, with apparent death, ending, after a time, in 
real death. The third stage was usually momentary, and seems to me 
to have been merely the dying, which occurred when the animal was 
exhausted and cyanosed by the convulsions. A notable symptom of 
thebaine-poisoning is the increase of bodily temperature, which Falck 
found to amount to from £° to 3° C. On pigeons (Falck and Ott) the¬ 
baine acts as upon mammals, and in frogs it produces the most violent 
tetanic spasms. The convulsions are undoubtedly spinal, as they occur 
after section of the cervical cord. 

The only detailed study of the physiological action of thebaine yet 
made is that of I. Ott ( Boston Med. and Surg. Journ., April, 1875), who 
found that the alkaloid does not directly affect the motor or sensory 
nerves or the striated muscles. The same observer also determined 
that thebaine exerts no influence on the inhibitory cardiac nerves, 
but does increase the arterial pressure by stimulating the vaso-motor 
centres, and probably also by stimulating the intra-cardiac ganglia. 
Thebaine is undoubtedly an exceedingly active poison. According to 
Albers, less than half a grain will cause violent tetanus in a frog, and 
in Ott’s experiments .011 grain produced very decided symptoms in the 
same animal. Harley found two grains sufficient to kill a bitch, and in 
Falck’s experiments a grain and a half injected hypodermically killed 
a dog in ten minutes. The alkaloid must act upon man as upon the 
lower animals; yet Fronmuller (Klin. Studien der Nark. Arzneimittel, 
Erlangen, 1869) affirms that he has given it in as high as six-grain 
doses without producing any symptoms, and that Professor Leidesdorff 
(Wiener Med. Wochenschrift, No. 34, 1868) had had similar results. 
Rabuteau is said to have taken 1.5 grain without decided symptoms. 
On the other hand, Eulenberg found one-four-hundredth of a grain 
to cause increased respiration, pulse-rate, and temperature, with some¬ 
times wide dilatation of the pupil (quoted by Ott). It seems impos¬ 
sible to avoid the conviction that the drug used by Fronmuller must 
have been either very impure or else not thebaine at all.. Husemann 
(Arch. f. Exper. Path. Pliarm ., ix. 422) has found chloral strongly anti¬ 
dotal to toxic doses of thebaine. 

Papaverine .—A great deal of discrepancy exists among observers as 
to the physiological action of papaverine, obviously dependent upon vari- 

12 


178 


GENERAL REMEDIES. 


ations in the purity of the specimens which they have used. Schroff 
and Hoffmann believe it to be inert in man, since the latter observer 
took about seven grains without any effect being induced. 

Albers and Claude Bernard claim that on animals it acts as a 
convulsant resembling thebaine; while Baxt asserts that in frogs it 
produces profound sleep, with great slowness of the heart’s beat, but 
without tetanus, and that it even acts as an antitetanic in the poison¬ 
ing of codeine and morphine. He also finds that rabbits and guinea- 
pigs bear enormous doses of it. Rabuteau says two to three centi¬ 
grammes produce violent convulsions in the frog, but twenty-five 
centigrammes in the dog cause no symptoms; yet in Baxt’s experi¬ 
ments four to ten centigrammes served to cause profound coma in the 
latter animal. Ott affirms that it is both narcotic and convulsant, and 
produces a condition of the muscles similar to that caused by veratrine. 
These statements are irreconcilable, and no opinion can be arrived at 
until new researches, prefaced by a rigid chemical study of the alkaloid 
used, are entered upon. 

Laudanine, discovered by Hesse ( Annalen der Chemie und Pharmacie , 
viii., Supplement. Bd., p. 272), has been elaborately investigated by 
Professor Falck, of Marburg* ( Deutsche Klinik, 1874, p. 298). He 
finds that there are three stages of its poisoning: first, hurried respi¬ 
rations, pupils contracted or dilated, muscular twitchings and convul¬ 
sive tremblings; second, convulsions closely resembling those of strych¬ 
nine-poisoning ; third, adynamia, apparent death, and finally death from 
failure of respiration, the heart being the last part of the body to die. 

Porphyroxine, according to Albers, acts upon the frog as the most 
powerful of all the convulsant opium alkaloids. Baxt (loc. cit., p. 123) 
found it in doses of two to three milligrammes (.030 to .045 grain) to 
throw the frog into a semi-comatose condition, followed in fifteen to 
twenty minutes by most violent convulsive excitement. In sparrows 
one milligramme (.015 gr.), and in pigeons a larger dose, produced vio¬ 
lent tremors, lasting ten to fifteen minutes, and followed by a state of 
semi-coma. In guinea-pigs ten to twenty milligrammes (.15 to .30 gr.) 
apd in rabbits a one-fourth to one-third larger dose, caused violent 
tetanic cramps; larger doses produced speedily fatal convulsions. Ac¬ 
cording to Schroff, 1.5 grains are without influence upon man. 

Cryptopine , according to Harley, causes in dogs wild delirium, with 
dilated pupils, followed by tetanic spasms. In the mouse, small doses 
produce some delirious excitement, followed by somnolency; while large 
doses cause heavy sleep, and death from failure of the respiration. 


* The following is the minimum fatal dose of alkaloids for rabbits, per kilogramme (2 lb. 
drm.) of weight, as determined by Falck: strychnine, 0.0006 gramme; thebaine, 0.012 
grm.; laudanine, 0.026 grm.; hydrocotarnine, 0.16 grm.; morphine, 0.72 grm. 



SOMNIFA Cl ENTS. 


179 


In the more detailed investigation of Immanuel Munk ( Wirkung des 
Cryptopin , Inaug. Diss., Berlin, 1873) it was found that the convulsions 
did not occur when artificial respiration was performed, and are, there¬ 
fore, probably not spinal. The death was preceded by loss of reflex ex¬ 
citability from spinal depression, and was due to respiratory paralysis. 
Enormous doses also killed the cardiac muscle. A grain and a half in¬ 
jected beneath the skin by Harley caused in some persons intense 
drowsiness, in others very slight symptoms. According to Dr. Ott. 
it is narcotic, exciting and then depressing spinal motor centres, para¬ 
lyzing spinal sensory centres, lessening functional activity of the motor 
nerves, and lowering heart-action by an influence on its muscle. 

Meconine, according to Albers ( loc. cit., p. 248), produces in (0.045 
grm.) the frog mild tremors, lessening of sensation, and finally death. 
On the higher animals its poisonous action is not very great. Orfila 
injected 0.06 grm. (0.9 gr.) into the jugular vein of a dog, without 
effect. Harley gave two grains hypodermically to the same animal, 
with no further result than a little abnormal quietness. According to 
the same observers, subcutaneous injections of fourteen gi'ains have 
no effect on the horse, but one-sixth of a grain produces very decided 
hypnotism in the mouse. On man, Dublanc ( Pharm . Centralblatt, 
1832), Schroff (Medicin. Jahrb ., 1870), Fronmiiller ( Klinische Studien 
Narcot. Arzneien), and Harley have found meconine, when given by the 
mouth, inert in doses varying from one to eighteen grains. Harley, 
however, asserts that in doses of one to two grains given hypoder¬ 
mically it acts upon man as a very excellent hypnotic; but Fronmiiller 
has injected nearly two grains with entirely negative results. 

Hydro cotar nine. —The physiological action of this alkaloid has been 
investigated by F. A. Falck (. London Medical Record , i. 218). He finds 
it more actively poisonous to rabbits than is morphine. In some of his 
experiments it produced tetanic convulsions, in others coma and stupor. 
In frogs the symptoms were always tetanic. 

In regard to the action of Pseudomorphine and Opianine we have 
little or no knowledge. Sertiirner, the discoverer of Meconic Acid 
(quoted bj 7 Albers), found it in his experiments to be actively poisonous ; 
but Sommering and Albers have come to an opposite conclusion. Large 
doses (one or two grains) do, however, affect frogs, although slowly, 
inducing a stupor-like condition, with convulsions. 

HYOSCINE. 

See Hyoscyamus. 

CHLORAL-HYDRATE OF CHLORAL. U.S. 

Chloral , which is itself not used in medicine, is an oily liquid which 
at the ordinary temperature gives off pungent fumes, and which is manu- 


180 


GENERAL REMEDIES. 


factured by the action of chlorine on alcohol. United with water, this 
oily liquid is converted into a hydrate. 

Chloral Hydrate ,* or Chloral of the U. S. Pharmacopoeia, is a vola¬ 
tile, crystalline solid, of a hot, burning taste, insoluble in cold chloro¬ 
form, but very soluble in water, ether, and alcohol. It occurs generally 
as transparent, colorless tablets, but sometimes in acicular or even in 
rhomboidal crystals. The compound of chloral and alcohol ,—Chloral 
Alcoholate ,—which resembles closely the hydrate, can be distinguished 
at once by its insolubility in water and its solubility in cold chloroform. 

If an alkali be added to a solution of chloral hydrate, it breaks up 
into formic acid and chloroform, which, when water has been the sol¬ 
vent, at once separates in the form of oily drops. 

Physiological Action.— When applied to a part, chloral acts as an 
irritant; and probably for this reason it sometimes, when given by the 
mouth, causes vomiting, or even purging. When it is given to man or 
other mammals in moderate doses, the most prominent result in the great 
majority of instances is a quiet sleep, as closely allied as possible to nat¬ 
ural sleep. The subject can readily be aroused from the lighter degrees 
of this, waking to full consciousness, but soon dropping off again when 
left quiet. The pulse is in this degree of action not affected, or is ren¬ 
dered a little slower; the pupil is contracted, but becomes normal so 
soon as the subject is awakened; the respiration is deep, full, and 
regular. When larger amounts are given, the sleep is much deeper, 
and may pass into profound coma; the respirations fall in number; 
the pulse is weakened and rendered slower, but may become rapid and 
irregular if the dose has been toxic; the temperature is reduced; the 
muscular system is relaxed, and both sensibility and reflex action are 
diminished. If a fatal dose has been given, all these symptoms are in¬ 
tensified : Avith coma, intense muscular relaxation, weak, thready pulse, 
and a pupil contracted at first, but afterwards dilated, the animal 
gradually sinks into death, paralyzed and anaesthetic. The immediate 
cause of death is usually a centric paralytic arrest of respiration; 
but in many cases there appears to be a simultaneous arrest of the 
cardiac action, and it is probable that fatal syncope may at times 
occur. At the post-mortem examination, congestion of the meninges 
and substance of the brain and cord, and of the lungs, is commonly 
found. The blood is thought by Bichardson (.Medical Times and Gazette , 
Sept. 4, 1870) to coagulate less firmly than when normal. 

The most constant and prominent of all the symptoms produced by 
moderate doses of chloral is sleep: this is without doubt due to a direct 
action of the drug upon the cerebrum. In most cases, as already stated, 
it is quiet, but sometimes it is restless, and in man has even occasionally 


* There is a chloral hydrate containing a very small proportion of water, which is insolu¬ 
ble in the latter menstruum. ( Gmelin’s Hand-Book.) For a case in which chloral was detected 
in the stomach after death, and for methods of examination, see Edinb. Med. Journ., Oct. 1878. 



SOMNIFACIENTS. 


181 


been wildly delirious; although it is somewhat uncertain whether the 
latter condition may not have been due to impurities in the drug. It 
seems to be well established that in the milder degrees of this sleep 
there is no anaesthesia. Demarquay ( Bulletin Therap., tom. lxxvii. p. 
307) claims that hypercesthesia very commonly follows the exhibition 
of small doses. Bouchut {New York Med. Gazette , Dec. 1870), Dieula- 
foy and Krishaber {Amer. Journ. Med. Sci. , Jan, 1870), Giovanni and 
Ranzoli ( Schmidt's Jahrbucher, Bd. cli.), and Rajewsky {Ibid.) confirm 
this, while Liebreich and Labbee* deny it, and Hammarsten, who has 
noticed such hyperesthesia, is inclined to think it apparent rather than 
real. I myself have seen this hyperesthesia, and there can be no doubt 
that it is an occasional, if not a constant, phenomenon. Rajewsky {loc. 
cit.) states that there is in frogs a corresponding period of over-excita¬ 
bility of the reflex centres, and that in rabbits he has noticed a glowing 
heat borne without much complaint, when pinching would produce 
violent outcries. In very large doses chloral produces anesthesia; but, 
unless the amount employed be so great as to be toxic, this anesthesia 
is in most cases very trifling. 

Motor System .—The paralysis and loss of reflex excitability induced 
by chloral are not muscular in their origin, for Labbee has found that 
after death the muscles respond perfectly to galvanism. Both Labbee 
{loc. cit.) and Rajewsky (loc. cit.) have found that the motor nerves are 
in no wise affected b}^ large or even fatal doses of chloral, which must 
therefore act upon the spinal cord to produce the paralytic phenomena. 
The experiments of Rajewsky have afforded positive confirmation of the 
conclusion arrived at by this process of exclusion; for he found that in 
the latter stages of chloral-poisoning direct irritation of the spinal cord 
gave rise to much less severe spasms than in the unpoisoned animal. 
Before this paralytic stage is reached, as already stated, Rajewsky 
affirms that in the frog there is a period of increased reflex activity, 
and that at this time stimulation of the spinal ganglia shows that they 
are more susceptible than normal. The observer last named states 
that these phenomena occur just as freely after destruction of Set- 
schenow’s centre in the frog as before, and are therefore independent 
of it. 

Circulation. —According to Demarquay, when chloral has been ad¬ 
ministered to animals there is evident enlargement and engorgement 
of all their blood-vessels; and Rajewskyf states that he has found 
sinking of the blood-pressure in rabbits from small as well as from large 
doses of the drug. On the other side, Labbee {loc. cit., p. 341) asserts 


* He has noticed it, however, in a single case, confined to the ears. ( Archives Ginerales, 
1870, tome xvi. p. 338.) 

f The work of Rajewsky was done under Professor Rosenthal, and the results, without 
the experiments, were published as an inaugural thesis. Of course half of its value is lost 
for want of the experimental records, and the subject needs re-investigation. I am acquainted 
with the pamphlet only through Schmidt's Jahrbucher. 



182 


GENERAL REMEDIES. 


that the rabbit’s ear grows pale after the injection of a very feeble dose. 
In man, Bouchut has obtained sphygmographic traces which he thinks 
indicate a primary increased arterial tension. Mancias, of Venice, has 
found the tension normal, but Anstie and Andrews (. American Journal 
of Insanity , July, 1871) confirm the results of Bouchut when small doses 
are employed. Preisendorfer (. Deutsches Archiv, xxv. 48), in a series of 
sphygmographic studies, thought there might be a brief primary rise 
of arterial pressure in man, as in animals, but under the full action of 
chloral the arterial pressure steadily sinks. After very large doses, 
according to both Andrews and Da Costa ( Amer. Journ. Med. Sci., April, 
1870), the tracings indicate decidedly lessened arterial pressure. What¬ 
ever may be the effect of small doses (and the point needs further in¬ 
vestigation), it seems well made out that, both in man and in animals, 
by large doses the blood-pressure is very much lessened, owing probably 
in part to vaso-motor paralysis, but in largest measure to an action of 
the drug on the heart. The vaso-motor palsy is probably chiefly due 
to an action upon the dominant centre, but Kobert ( Therajo. Gaz ., 
1887) has shown that there is also, after a very large dose of the chlo¬ 
ral, palsy of the coats of the vessels. Various observers state that 
there is in man and in the lower animals at this time slowing of the 
pulse which, according to Bajewsky, is in the frog and rabbit altogether 
independent of the inhibitory nerves, since it occurs after their sec¬ 
tion. When toxic doses have been enrployed, the heart, after numerous 
pauses, is finally arrested in diastole. Analogy indicates very strongly 
that this arrest is due to a direct influence upon the heart-muscle or 
ganglia, but Labbee affirms that chloral placed freely upon the frog’s 
heart slows but does not stop its contractions, and that after section 
of the cord in the chloralized frog the heart will continue beating for 
hours. These results obtained by Labbee are, however, contradicted 
by the more recent and thorough study of the effect of chloral upon 
the isolated heart of the frog by Drs. Sydney Binger and H. Sainsbury, 
who found that chloral lessened the frequency and power of the spon¬ 
taneous contractions, and also the excitability of the cardiac muscle, 
and finally caused a diastolic arrest (Brit. Med. Journ., March, 1883). 

In poisoning in man, the pulse has towards the last been very feeble, 
generally rapid and irregular, and even in some cases in which recovery 
has occurred it has been altogether absent for a time. The experiments 
of Binger and Sainsbury are so concordant with this that I have no 
doubt that chloral is a direct depressant to the heart, and is capable of 
suddenly and unexpectedly destroying life, precisely as does chloroform. 

Respiration. —In full doses, chloral lessens the number of respirations 
per minute, causing them to become slow and full; when toxic doses 
are taken this action becomes more and more marked, the rhythm is 
very much affected, and the respiration grows very irregular, and some¬ 
times very rapid and shallow, until it ceases. As these phenomena 
occur equally after section of the vagi (Bajewsky), the influence of 


SOMNIFACIENTS. 183 

chloral must be exerted upon the respiratory centre at the base of the 
brain. 

Temperature .—A most remarkable action of chloral is upon the tem¬ 
perature : in this point all observers are in accord with Dr. .Richardson, 
of London, who has seen the temperature fall 6° F. in a rabbit which 
recovered. Bouchut has noticed a fall of 2° (C. ?) in an infant, and 
Da Costa and other observers have noticed slighter reductions of tem¬ 
perature in man after therapeutic doses. In a case reported by Dr. 
Levinstein ( Lancet , i., 1874), after six drachms of chloral the temper¬ 
ature rose to 39.5° C. (102.1° F.), and subsequently fell to 32.9° C. 
(91.22° F.). Hammarsten has found that the fall of temperature is 
very rapid, 6° C. in an hour, and that it occurs in animals well wrapped 
up and laid in a warm place. 

The physiological action of chloral may be summed up as follows. 
Upon the cerebrum it acts as a very powerful and certain hypnotic; in full 
doses it acts as an intense depressant upon the centres at the base of the 
brain, and upon the spinal cord, and also causes slowing and weakness of 
the heart’s action, probably vaso-motor pai’alysis, slowing of the respira¬ 
tion, and muscular weakness, with a certain amount of anaesthesia; in 
fatal doses it usually produces a gradual death by paralyzing the nerve- 
centres in the medulla, and thereby arresting respiration, although in 
rare cases it kills suddenly by directly paralyzing the heart, which 
always stops in diastole. Its action in very small doses is uncertain, 
but there is considerable evidence to indicate that it irritates or stimu¬ 
lates the spinal and the cardiac, and even the vaso-motor, centres. On 
the vagi and on the motor nerve trunks it has no marked influence. 

Action as Chloral. —The conversion of chloral by alkalies in solution 
into chloroform and formic acid first suggested its use in medicine to 
Liebreich ( Wiener Medizinische Wochenschrift, August, 1869); and the 
theory that its action is really due to chloroform generated by the 
alkalinity of the blood has been received with favor by Personne and 
other writers. The evidence by which this theory is to be disproved 
or established is twofold in its nature,— i.e., chemical and physiological. 

Personne ( Journal de Pharmacie et de Chimie, 1870), by distilling the 
blood of animals poisoned by chloral at 40° C., a temperature decidedly 
above that of the body, obtained chloroform; and his results have been 
confirmed by Pellogio ( Schmidt’s Jahrbuclier, Bd. cli. p. 89) and other 
chemists, so that I think their correctness is not to be questioned. 
They are, however, not decisive, for it is possible that the chloroform 
may be formed during the distillation, owing to the comparatively high 
heat employed. This evidence is, then, to be thrown out, especially 
as Hammarsten {Ibid., Bd. cli.) has found that if chloral be mixed 
with fresh blood and streams of carbonic acid be forced through it, no 
chloroform can be detected, but if the mixture be heated the latter 
can be obtained in abundance. Further, in dogs deeply poisoned with 
chloral the same observer examined the expired air and a portion of 


184 


GENERAL REMEDIES. 


the blood without finding chloroform, although when a clyster of the 
anaesthetic was given to the poisoned animal chloroform could be de¬ 
tected in a few minutes in both the blood and the breath. In non- 
chloralized animals to which similar enemata were given, the chloroform 
could be found in the breath before anaesthesia was induced. Rajewsky 
{Ibid., Bd. cli.), Amory ( New York Med. Journ., 1870), and Von Mering 
and Musculus ( Berichte Deutsches Chem. Gesell., 1875, i. 662) have con¬ 
firmed these results: so that it may be considered settled that chloral 
mixed with blood at ordinary temperatures remains unaltered, and that 
in the most severe poisoning no chloroform can be detected either in 
the blood or in the expired air. Ilammarsten examined the blood 
and expired air unsuccessfully, for chloral, in dogs poisoned with the 
drug; but Amory ( loc. cit., p. 616) has obtained from the blood acicular 
crystals, evidently of chloral. The exact fate of chloral in the system 
can scarcely be considered as established, but it is probable that it is 
eliminated with the urine, and at least partially in a changed condition. 
A. Tomascewicz recognized it in the secretion mentioned by means of 
the delicate isocyanphenol reaction* of Hoffmann ( Pfluger's Arclxiv, ix. 
35). Feltz and Ritter ( Comptes-Pendus, lxix. 966) believed that they 
found sugar in the urine of chloralized animals, but both Von Mering 
and Musculus {loc. cit., 663), and F. Echardf {Archiv f. Exper. Pathol, 
und Pharm., xii. 276) have shown that the substance which reduces the 
copper solution will not undergo fermentation, and Von Mering and 
Musculus have separated it as urochloralic acid in colorless, shining 
needles, often arranged in star-like groups, soluble in water and in alco¬ 
hol, insoluble in ether. The existence of this acid has been confirmed 
and its chemical properties studied by A. Borntraeger {Inaug. Dissert., 
Marburg, 1879), and by E. Kfilz {Arch. f. Gesammte Physiolog., 1882, 
506), who found it destitute of hypnotic or other active physiological 
powers. 

The phj^siological evidence is in strict accord with the chemical in 
showing that chloral is not converted into chloroform in the system. 
While chloral produces a longer and more intense sleep than does chlo¬ 
roform, the latter agent acts much more decidedly as an anaesthetic. 
Again, Djurberg {Schmidt's Jahrbucher, Bd. cli. p. 84) has shown that, 
while after chloroform-poisoning biliary coloring-matters appear in 
the urine, after chloral-poisoning none can be detected, and that when 
chloral is added to blood outside of the body no destruction of the red 
disks occurs. 

As was first shown by Cohnheim, if the abdominal vein of a frog be 
opened and salt water be injected until almost all the blood is washed 

* Many chemists have failed to find chloral for want of a delicate test. Dr. F. Ogston 
( Edinb. Med. Surg. Journ., xxiv. 292) affirms that the sulphide of ammonium affords a means 
of recognizing minute amounts of the drug. 

f Echard has also found that chloral will prevent the development of diabetes by the 
Bernard prick. 



SOMNIFA CIENTS. 


185 


out and the circulatory system is filled with the foreign fluid, the ba- 
trachian will live from one to three days in apparently perfect health. 
Both Rajewsky ( loc. cit., p. 91) and Lewisson ( Reichert's Archiv fur 
Anatomie und Physiologie , 1870, p. 346) have found that upon these 
“ salt frogs,” with the circulating fluid completely neutral, the chloral 
acts precisely as in the normal frog. 

I think the evidence which has been adduced completely disproves 
the chloroform theory, and forces assent to the proposition that chloral 
acts directly upon the organism. 

Therapeutics.— The results of the clinical use of chloral are in 
strict accord with its known physiological action. The indication 
which it most usefully meets is to induce sleep. The more purely ner¬ 
vous the wakefulness is, the more successful is this remedy. When 
from functional over-excitement of the brain due to excessive mental 
strain, or from anxiety or other kindred cause, the patient cannot sleep, 
chloral is by far our most valuable hypnotic. On the other hand, when 
severe pain causes wakefulness, chloral is of very little value,—at least 
in doses which I think safe. Sometimes even in these cases sleep will 
come, but it will very often be a restless, troubled sleep, with moaning 
or other indications of suffering; and it may be that the patient on 
awaking will complain that he has suffered more while sleeping than 
when awake. 

In the sleeplessness occurring at times during convalescence from acute 
disease, chloral is very efficacious. In the early stages of fevers it is 
sometimes of advantage; Dr. Russell ( Glasgow Med. Journ ., Feb. 1860) 
recommends it especially in the ivild delirium of typhus in its earlier 
stages. In advanced fever-cases, when the symptoms are gravely 
adynamic, I conceive that the use of chloral would be very perilous. 
In delirium tremens it often induces sleep readily, but not rarely it fails, 
even in large dose. In the sleeplessness of acute puerperal or non- 
puerperal mania there is abundant testimony to the value of chloral. 
It must not be forgotten that chloral is a dangerous remedy when there 
is cardiac weakness; and when in any of the diseases just spoken of 
there is reason to suspect a fatty or even a feeble heart, great care 
must be exercised in the administration of chloral. Under such circum¬ 
stances the dose of ten grains should not be exceeded, and should not 
be repeated more than once unless after an interval of several hours. 

Dr. Lyon Playfair ( Lancet , 1874, vol. i.) has introduced the use of 
chloral as a means of alleviating the sufferings of parturition, and has 
been followed to some extent by other practitioners. He affirms that it 
produces a drowsy state, from which the woman is aroused by the uter¬ 
ine contractions, which are almost robbed of their painful character. 
So soon as the “ pains” begin to be active he administers fifteen grains 
of the drug, repeating the dose in twenty minutes; thirty grains usu¬ 
ally are sufficient, and he has never given more than a drachm during 
a labor. Towards the close, wffien the “pains” become very severe, 


186 


GENERAL REMEDIES. 


inhalations of chloroform or of ether may be practised in the usual 
manner. It is affirmed by other obstetricians that in rigidity of the os 
chloral is often of great service, by aiding in the desired relaxation, and 
at the same time materially alleviating suffering. 

On the whole, as a pure hypnotic chloral is indeed unequalled, and 
may be used in all cases when no contra-indication exists. 

The second indication to meet which chloral may be employed is 
to relax spasm. For this purpose it has been used with advantage 
in puerperal and uraemic convulsions. It must be remembered that in 
many of these cases, although next to chloroform the best palliative, it 
is only a palliative, and must only be used to quiet the nervous dis¬ 
turbance until other remedies can have time to act. In tetanus it has 
been claimed that chloral is the remedy. Dr. Jos. R. Beck (> St. Louis 
Med. and Surg. Journ., June, 1872) has collected, of the traumatic form 
of the disease, thirty-six cases, with twenty-one recoveries, in which 
chloral constituted the whole or the major part of the treatment. 
References* are given below to fifty-six cases in addition; so that the 
figures stand forty-eight recoveries and forty-four deaths. These 
results do not seem to warrant the high estimate which has been set 
upon the value of chloral in tetanus. Dr. Macnamara ( Practitioner , 
November, 1874) has employed the remedy in a different way from 
what is usual. Believing that it exerts very little control over the 
spasms, he has not used it for such purpose, but has used it simply 
as a hypnotic, giving the patient forty grains of it at bedtime, and only 
when the temperature rises above 101° F. a single dose of thirty 
grains in the morning. No other medicine is given, but the patient is 
made to swallow four ounces of milk with brandy every four hours, 
one egg being mixed with the milk morning, noon, and evening. lie 
asserts that in this way out of twenty consecutive cases (all trau¬ 
matic?) occurring in natives of India he has saved seventeen. My 
own opinion is that no one single remedy affords the best chances in 


* Recovery. —Fergusson ( Edin. Med. Journ., July, 1871); Watson ( Lancet, 1870); Bart¬ 
lett; May; Ballantyne; Cushing ( Pacific Med. and Surg. Journ.)] Lovegrove (Brit. Med. 
Journ., 1872, p. 493); Herndon (Atlanta Med. and Surg. Journ., 1873, p. 69); Macnamara 
(Indian Med. Gaz., April, 1871); Richelot (Bulletin Thirap., Ixxxvi.); Lucian Papillaud 
(Gaz. Midicale, 1875, p. 176); Bourdy (Bull. ThSrap., Ixxxvi.); Cane (Lancet, 1876, i. 564); 
Cauvy (Bull. Thirap., xciii. 186); Durand (Centralbl.f. Chirurgie, 1876, 778); Laurens (Le 
Progris Med., 1876, 180); Pugliese (Journ. de Therap., 1875, 244): each 1 case; Cargile 
(Lancet, 1877, ii. 158,) 3 cases; Boon (London Pract., xx. 161), 2 cases; Roberts (Amer. Jour. 
Med. Sci., lxxiv. 420), 3 cases; Garnett (Cincinnati Lancet and Clinic, 1880, 316), 2 cases. 

Fatal. —Porta (Schmidt’s Jahrbucher, Bd. cli. p. 110), 2 cases; Macnamara (Indian Med. 
Gaz., April, 1871), 6 cases; Baudon (Bulletin Thirap., Ixxxvi.), 3 cases; Blin (Ibid.), 3 cases; 
Petit (Centralbl. f. Chir., 1876, 792), 3 cases; Roberts (Amer. Journ. Med. Sci., lxxiv. 420), 3 
cases; Cruveilhier (intravenous) (Bulletin Therap., Ixxxvi.); Labb6e (Ibid.) ; Itard (Schmidt’s 
Jahrb., Bd. cli.); Lannelongue (Bulletin Thirap., lxxxvii., 1874); Verneuil (Ibid., Ixxxvii., 
1874); Boon (London Practitioner, xx. 161); Boucquier (Centralbl.f. Chir., 1876, 717); 
Bresson (Le Progris Med., 1876, 180); Pugli&se (Journ. de Therap., 1875, 244): each 
1 case. 



SOMNIFACIENTS. 


187 


tetanus, but that a combined use of bromide of potassium, opium, and 
chloral should constitute the basis of treatment, the patient also being 
supported with food to the utmost. In strychnine and other toxsemic 
convulsions chloral is often of great value * 

In trismus nascentium Dr. Widenhofer [Boston Med. and Surg. Journ., 
1874) recommends it very highly. He says that in the Children’s Hos¬ 
pital he formerly lost all his cases, but that by its use he has saved six 
out of twelve. He gives it to a young babe in one- and two-grain doses 
by the mouth, or, when the spasms prevent, in double the quantity by 
the rectum. In chorea chloral has been used sometimes with great ad¬ 
vantage, more often, I think, with the result of simply diminishing tem¬ 
porarily the choreic movements, and sometimes without any effect. In 
my own experience the movements have generally returned with un¬ 
abated violence so soon as its exhibition was suspended. As a nocturnal 
quietant and hypnotic, it would appear to offer very great advantages 
in cases of acute chorea in which speedy death is threatened from the 
incessant and violent movements; also in cases complicated with frac¬ 
tures, where a temporary lull is of importance. 

In puerperal convulsions its use in large doses has met with a great 
deal of favor (see Phila. Med. Times , vol. iv.). A half-drachm may be 
exhibited at once, and half the quantity every hour or two pro re nata. 

In the convulsions of children it has been employed with apparent 
good; in cramps in pregnant women it has been commended by Dr. 
Morgenstern ( Wiener Med. Presse, Nov. 1871); in singultus, by Dr. 
Leavitt ( Amer. Journ. Med. Sci., April, 1871) ; in the spasmodic nocturnal 
enuresis of children, also, it may often be used with advantage (Dr. J. 
B. Bradbury, Brit. Med. Journ., April, 1871); in laryngismus stridulus 
(Dr. Rehn, Jahrbuch fur Kinderkrankheiten, 1871) and other spasmodic 
affections; in nocturnal emissions at bedtime it is of service (Gascoyne, 
Brit. Med. Journ., 1872). In whooping-cough it would seem to be of 
very great value, as has been attested by Drs. Adams ( Lancet , i., 1870), 
Murchison, [lbid.,ii., 1870), Rigden [Practitioner, xxx ii., 1870), and Water- 
house [Ibid., Dec. 1870), and by various French observers. Small doses 
(two to eight grains), repeated at regular intervals during the day, are 
often very efficacious. Another plan, especially useful when the parox¬ 
ysms are very severe at night, is to give a full dose at bedtime. When 
there is a tendency to bronchitis and pneumonia, chloral must be used 
with care, as in large doses it favors congestion of the lungs: yet 
Murchison saw a very threatening case, complicated with bronchitis 
and pneumonia, greatly benefited by its exhibition. In asthma it has 
sometimes been of use, but more often it has failed. Its hypodermic 
use in the algid stage of cholera, as recommended by Dr. Hall [Lancet, 
May 2, 1874), appears to me of very doubtful value. 


* For a paper discussing the relations of chloral to various mostly unimportant alkaloids, 
Bee Arch./. Exper. Path, und Therap., is. 440. 



188 


GENERAL REMEDIES. 


The third indication for which chloral has been used is to relieve 
'pain. That it will do so when given in very large doses there can be 
no doubt; but, unless the dose be so large as to be dangerous, ray ex¬ 
perience of chloral is that it is of little value as an anaesthetic. Its 
powers in this direction are incomparably less than those of opium, and 
its habitual use is probably attended with very grave dangers. 

Theoretically, chloral might be of use to reduce temperature. Its 
other active properties will probably completely interfere with its use 
for this purpose in the vast majority of such cases, especially as, in 
order to check the development of animal heat, the dose must be very 
large. When, however, there is a high sthenic state of the system, it 
might be tried with caution; but clinical experience is almost entirely 
wanting. I know of but a single case (Med. Times and Gaz., Nov. 
1869) reported: in this its use is said to have given satisfaction. 

Locally a solution of chloral (25 per cent, to saturation) has been used 
with asserted good effects as a stimulant and antiseptic in foul ulcers, 
buboes, bedsores, etc., especially when the discharge is free. It is also 
stated that it gives great relief from pain in uterine and other cancers. 
Applied to the skin, chloral acts as a powerful irritant, and it has been 
proposed as a vesicant, but is said to cause excessive pain. See New 
York Med. Journ., xxxvii. 445. 

Professor Ore, of Bordeaux, has proposed intravenous injections of 
chloral as a substitute for ether and chloroform in surgery, and as a 
means of combating tetanus. His suggestion has been carried out by 
himself and others in a number of cases with asserted good results. But 
in other instances it has apparently caused death, and its use is, in my 
opinion, absolutely unjustifiable. The risks are twofold. Under any 
circumstances chloral occasionally acts with unexpected violence, and it 
has caused death even when exhibited by the mouth in what are usually 
considered safe doses. It is plain that this danger is vastly increased 
by throwing the whole dose at once upon the heart and nervous system. 
Every one who has practised intravenous injections in animals must 
be aware of the extraordinary results of throwing the poison almost 
undiluted into the cavities of the heart. Again, chloral exerts a very 
great influence on fibrin, and has even been used to coagulate the blood 
in varices; the intravenous use of the drug may, therefore, be produc¬ 
tive of thrombi; indeed, M. Tillaux has reported a case in which a 
venous coagulum was found after death extending up the arm even into 
the axillary vein, and accompanied by a white heart-clot.* 

The antiseptic powers of chloral were apparently first noticed by 
MM. Dujardin-Beaumetz and Hirne in 1872 (see Bulletin Therap ., 


* Any one desirous of following this subject further will find the following references of 
value: 

Archives Gin., ii., 1874; Bulletin de VAcad., xxxviii., 1874 ; Gaz. Mid., xlv., 1874; Gaz. 
Mid. de Bordeaux, xiii., 1874; Gaz. des Hopitaux, 1874; Le Progris Mid., 1874; Journal 
de Thirap., 1874; Presee Mid. Beige, Oct. 1874. 




SOMNIFA Cl ENTS. 


189 


lxxxvi. 224). Recently the subject has been investigated by various 
observers, especially by Dr. Keen ( Phila. Med. Times, vol. iv.) and M. 
Personne. It has certainly been shown that a solution of twenty to forty 
grains to the ounce will preserve animal tissues for a great while, and 
probably indefinitely. Moreover, the finest microscopical structure ap¬ 
pears not to be altered by a solution of this strength. Dr. Keen’s first 
experiences led him to hope that, as chloral does not materially affect 
the color of the tissues, it might be useful in the dissecting-room, and 
subsequent trials of it have confirmed Dr. Keen’s first hopes ( Amer. 
Journ. Med. Sci., July, 1875). Dr. Keen has also had great satisfaction 
in the use of chloral to keep free from odor the urinals of paraplegics 
and other patients suffering from incontinence. 

Toxicology. —That chloral is a dangerous agent, capable of destroy¬ 
ing life, is attested by a number of published cases; but this is true 
of other drugs; and the practical point to be determined is, Does it 
ever act out of proportion to the amount ingested ? or, in other words, 
does the ordinary therapeutic dose ever become toxic, and does it ever 
act in a cumulative, unexpected manner? Abroad, it has very com¬ 
monly been prescribed in half-drachm and even drachm doses, and in 
the vast majority of cases without any bad results. That thirty grains 
is not a safe dose is shown, however, by the case of Dr. Reynolds 
(.Practitioner , March, 1870), in which forty-five grains caused most 
alarming symptoms; by that of Dr. Watson (Med. and Surg. Reporter , 
Jan. 27, 1871), in which eighty grains, given in ten-grain doses spread 
over thirty-six hours, nearly proved fatal; and especially by a number 
of cases recorded by Dr. H. W. Fuller ( Lancet , March, 1871), in some 
of which very alarming symptoms followed the exhibition of thirty 
grains, and in one death in a healthy young woman of thirty. Dr. 
Schwaighofer, of Yienna, records ( Irish Hosp. Gaz., 1873) coma and 
death in a drunkard following the ingestion of half a drachm. Dr. W. 
H. Lathrop ( Year-Book of Therapeutics and Pharmacy , 1872, p. 254) 
records the case of a man previously healthy, but suffering from de¬ 
lirium tremens, who took sixty grains between 12 and 1 p.m., at 2.30 p.m. 
twenty grains more, and at 3 p.m., no effect being manifest, twenty 
grains more. His physicians then left him sleepless and complaining 
only of a slight paralysis of the lower extremities; and almost in a 
moment he was dead. Other cases might be quoted (see Berlin. Klin. 
Wochenschrift, 1876), but the above are sufficient to show that chloral 
may kill suddenly and unexpectedly. 

An observation of Professor Yulpian ( Comptes-Rendus , lxxxvi. 1303) 
throws much light upon these sudden deaths. He found that gal¬ 
vanization of a divided vagus would cause in a chloralized animal not 
momentary, but permanent, arrest of respiration, if the centric end 
was selected, or permanent diastole of the heart if the distal part of 
the nerve was attacked. It is very probable that in a man under the 
influence of chloroform or of chloral, death may be precipitated by a 


190 


GENERAL REMEDIES. 


slight peripheral inhibitory irritation. I think the practical deduction 
from the known facts is that twenty grains is the highest safe dose of 
chloral; that this amount should not be repeated oftener than once an 
hour, and, when sixty grains have been taken, not again for some hours, 
unless in very urgent cases, as acute tetanus or violent chorea threat¬ 
ening speedy dissolution. On the other hand, recovery has been re¬ 
ported by Dr. Eshleman ( Phila . Med. Times , Oct. 1870) after the in¬ 
gestion of four hundred and sixty grains. There are no lesions found 
after death from chloral which can be considered pathognomonic, but 
a dark, bloated countenance and other evidences of death from asphyxia 
have been noted in some cases. 

The treatment of chloral-poisoning is identical with that of opium¬ 
poisoning, consisting in the free use of alcoholic and external stimulants, 
such as sinapisms, dry heat, frictions, flagellations, etc., to maintain the 
circulation, and of shaking, walking, application of dry electric brush, cold 
douches, etc., to keep up the respiration. In practising these measures 
it must be remembered, however, that the patient in chloral-poisoning 
is much more apt to die of exhaustion, and especially of cardiac failure, 
than in opium-poisoning, and that therefore those methods of arousing 
the nerve-centres which do not, like walking, require the expenditure of 
effort on the part of the patient are to be preferred. Artificial respira¬ 
tion should always be resorted to before natural respiration altogether 
fails; and Clemens ( Schmidt's Jahi’bucher, Bd. cli. p. 99) has found that 
animals asphyxiated by chloral may often be at once aroused by the 
inhalation of oxj^gen. Hypodermic injections of strychnine have been 
recommended on theoretical grounds, and a case is reported by Dr. 
B. W. Stone ( Louisville Med. News, xv. 179), in which four hundred 
and twenty-five grains of chloral were ingested, and recovery oc¬ 
curred after the hypodermic use of one-fifth of a grain of strychnine 
in divided doses. Atropine seems to me a very rational remedy, and 
Dr. I. M. Booth reports a case ( Lancet , 1884, i. 468) of recovery after 
about one hundred and ten grains of chloral under the use of tincture 
of belladonna. Probably it will hereafter be found that it is very im¬ 
portant in all forms of threatening narcotism to maintain the animal 
heat. Dr. Lauder Brunton has shown ( Journ. Anat., viii., 1874) that 
if the bodily temperature be maintained artificially animals survive 
doses of chloral usually fatal, or recover consciousness more quickly 
than is normal after small doses. The inference is very obvious that in 
human chloral-poisoning, by the use of dry external heat, hot blankets, 
hot baths, and other devices, the warmth of the patient should be main¬ 
tained. 

Considerable attention has been given both in this country and 
abroad to the subject of chronic chloral-poisoning; and, while some 
affections have been erroneously attributed to the drug, there seems 
to be no doubt that its long-continued use often does produce serious 
symptoms. The cases are divisible into two or three groups, which 


SOMNIFA Cl ENTS. 


191 


are, however, really artificial, as is shown by the occurrence of cases be¬ 
longing to two or even three of the groups. The first of these includes 
those patients in whom the respiration is chiefly affected. The dyspnoea 
may he slight, and may only be felt at times, as after exertion or after 
meals; but it may be constant and alarming. Cases of this character 
are reported by Jastrowitz, by Schule, and by Ludwig Kirn ( Allgem. 
Zeitschrift fur Psychiatrie, xxix., 1872 ; Practitioner ). In one instance 
(Professor 1ST. R. Smith, Boston Med. and Surg. Journ., 1871) death from 
bronchial effusion is believed to have been caused by chloral. Dr. Kirn 
affirms (Berlin. Klin. Wochenschr., xx. 721) that in some cases mental 
disturbance with hallucinations occurs. 

In the second group of cases, eruptions of the skin are the chief 
manifestations of the toxaemia. In the mildest of these there is no 
distinct rash, only the occasional appearance of transient red blotches 
on the face or neck. But a very extraordinary tendency exists to¬ 
wards the production of a rash or discoloration at the slightest cause, 
so that drinking a glass of wine will produce an intense, even livid, 
erythematous redness of the face. In other instances there is marked 
erythema (Schule, Allgem. Zeitschr. fur Psychiatrie , xxviii.), occurring 
first in spots upon the face, but extending downwards to the trunk, 
becoming more and more general, and showing a marked tendency to 
follow the nerve-trunks. This erythema is seemingly due to vaso¬ 
motor weakness, and consequently is allied to other more urgent symp¬ 
toms seen in chloral toxaemia. Sometimes it invades the mucous mem¬ 
branes, which become red, swollen, and cedematous; and if the glands 
are involved, as in a case reported by Dr. Chapman ( Lancet , 1871), the 
result may be serious. A deeper implication of the vaso-motor and 
cardiac nervous system was probably the cause of the genei’al oedema, 
profound weakness, and failure of heart-action in the case recorded by 
Professor N. R. Smith (foe. cit.). Professor Smith also calls attention 
to desquamation of the cuticle and ulcerations about the nails as being 
present in these cases. 

In the third group of cases, petechise, ecchymoses, ulcerations, and 
even high fever and other pysemic symptoms, are asserted to have been 
produced by the continuous use of chloral. It seems to me, however, 
very doubtful whether the drug really was the cause of the symptoms 
which have been recorded by Crichton Brown, by Monkton, and by 
Kirn. 

The habitual use of chloral as a narcotic has been indulged in, it 
is asserted, to a considerable extent, and Dr. George F. Elliott reports 
(Lancet, 1873, i. 754) a case in which “delirium tremens” followed the 
withdrawal of the accustomed draughts. 

Administration. —Sufficient has been said as to the dose of chloral. 
It is best given diluted with a weak syrup. 

Metachloral is prepared by acting on chloral hydrate with sul- 


192 


GENERAL REMEDIES. 


phuric acid. The hard white substance which forms after a few days 
is washed with water and dried by means of chloride of calcium; then, 
mixed with gum, it is formed into crayons which are coated with par¬ 
affine for external use as a counter-irritant and local anaesthetic. It is 
said to be less irritating than chloral ( Lancet , i., 1874). 

Chloral Camphor.— Equal parts of chloral and camphor rubbed 
together produce a clear liquid. Dr. Lenox Browne claims that this 
“ when painted over the painful parts and allowed to dry” gives the 
greatest relief in neuralgia , and that in toothache it is equally efficacious. 
It occasions tingling of the skin, but never blisters, and has been com¬ 
mended in ‘pruritus. A drachm of it swallowed by mistake produced 
very severe prostration, feebleness of the pulse, vomiting, fifteen “ cof¬ 
fee-ground” stools, and prolonged narcotism, with brief semi-delirious 
periods, lasting four days ( Amer. Journ. Med. Sci., lxxix. 90). Dr. D. B. 
Simmons, who reports the case, has since found chloral camphor, in 
doses of ten to twenty drops, to be very powerful as a sedative narcotic 
in mania, etc. 

Butyl-Chloral Hydrate.— The substance brought forward as a 
remedy by Oscar Liebreich under the name of croton-chloral hydrate is 
formed by the action of chlorine gas upon aldehyde. It crystallizes in 
small glittering tables,* and is soluble with difficulty in water. It is 
now stated to be really butyl-chloral, which, when brought in contact 
with an alkali in solution, breaks up into chloride and formiate of 
sodium, and bichlorallylene. According to Liebreich {Brit. Med. Journ., 
Dec. 20, 1873, and Feb. 1876), a drachm of this substance, dissolved 
in water, and introduced into the stomach, produces in the course of 
from fifteen .to twenty minutes a deep sleep, accompanied by anaesthesia 
of the head. While the eyeball has lost its irritability, and the trigem¬ 
inus nerve shows no reaction whatever on being irritated, the tone of 
the muscles remains unaltered. The effect upon the pulse and respira¬ 
tion is also stated to be much less than that produced by equiva¬ 
lent doses of chloral hydrate. Liebreich declares that the symptoms 
after large doses are deep sleep, trigeminal anaesthesia, and death by 
arrest of respiration. The circulation, he affirms, is kept up with great 
tenacity, and, even if cardiac action, as well as respiration, has ceased, 
artificial respiration is able to restore the action of the heart immedi¬ 
ately, and the life of the animal may thus be saved. Immense doses 
of croton-chloral produce cardiac paralysis. According to the author 
just quoted, the value of the drug is in its power of lessening sensi¬ 
bility before producing narcosis. These assertions of Liebreich are not 
borne out by the seemingly much more elaborate researches of J. V. 


* For a detailed account of physical and chemical characters, see a paper by E. Schering, 
Neues Repertor. fur Pharm., Bd. xxi. Heft 5, 1872, which I have abstracted into Neio Reme¬ 
dies , vol. ii. 



SOMNIFA Cl ENTS. 


193 


JVlering {Arch. f. Experm. Pathol. Pharm., Feb. 1875). He found that 
the sensibility of the cornea was not abolished until the respiration 
was reduced to one-half its normal rate. In dogs, cats, and rabbits 
the blood-pressure was reduced temporarily by small doses, perma¬ 
nently by larger ones. Intravenous injections of sufficient quantity 
and concentration were followed by immediate arrest of the heart. 
Altogether, the symptoms caused by croton-chloral seemed exactly 
parallel with those induced by chloral hydrate. H. Windel Schmidt 
( Centralhl. f. Chirurgie , 1877, p. 210) also found narcosis to precede the 
anaesthesia of the head. According to E. Kiilz, butyl-chloral is elimi¬ 
nated as urobutylchloralic acid , a substance analogous to urochloralic 
acid {Arch. f. G-esammte Physiol., xxviii. 534). 

Croton-chloral has been highly praised by Liebreich for its powers 
of relieving neuralgias and other painful affections of the trigeminus. 
He affirms that it will afford relief even in severe tic-douloureux , but is, 
unfortunately, only palliative. His statements have been confirmed by 
Drs. J. W. Legg ( Lancet, 1873), Benson Baker {Brit. Med. Journ., Oct. 

1873) , J. B. Yeo ( Lancet , Jan. 1874), Sydney Ringer {Brit. Med. Journ., 

1874) , and F. B. Lee {Ibid.'). In a single very severe case of centric 
tic under my own care, ten grains of the drug have given very decided 
temporary relief, and compelled sleep. It is usually administered in 
doses of from five to twenty grains, in syrup. The safest plan is to 
give five grains every half-hour until thirty grains have been taken or 
relief afforded. Liebreich uses it according to the following formula: 
butyl-chloral hydrate, 5 to 10 parts; glycerin, 20 parts; distilled water, 
130 parts. Dose, half an ounce, followed in five minutes by a second, 
and ten minutes later by a third unless relief is afforded. 

PARALDEHYDE. 

Acetic aldehyde is obtained by the action of an oxidizing agent, as 
chromic acid, upon alcohol. The aldehydes are various, chloral itself 
being trichloraldehyde, but acetic aldehyde is the one usually known 
simply by the name of aldehyde. It exists in two polymeric modi¬ 
fications.—one being paraldehyde and the other metaldehyde. Par¬ 
aldehyde may be prepared by heating acetic aldehyde with a> small, 
quantity of hydrochloric acid or with zinc chloride. Its formula is 
(C 2 H 4 0) s or C 6 H 12 0 6 , which latter represents the addition (combination) 
of the three molecules represented in the first formula. It is a colorless 
liquid, having a boiling-point of 123.5° C., and a very disagreeable odor 
and taste. Metaldehyde may be prepared by passing gaseous hydro¬ 
chloric acid through acetic aldehyde and then cooling with a freezing 
mixture. It crystallizes in needles or tetragonal prisms. 

Physiological Action. —The physiological action of paraldehyde 
was first investigated by Dr. Cervello {Archiv /.. Exper. Path. Pharm., 
xvi. 265), whose results have been confirmed and- extended by Alber- 
toni {Arch. Ital. de Biol.), Quinquad {Gompt.-Rend. Soc. Biolog., 1884), 

13 


194 


GENERAL REMEDIES. 


Henocque (Ibid.), Yulpian (Ibid.), Bochefontaine (Ibid.), and Prevost 
(Internal. Congress, 1884, vol. i.). In frogs it produces sleep, with loss 
of sensibility and complete relaxation of the muscular system, without 
affecting the cardiac movements or the vagi or motor nerves. After 
toxic doses death occurs from paralysis of the respiratory centre. In the 
rabbit doses of thirty-five to forty-five grains cause profound sleep, with 
progressively diminishing respiration, and at last death from asphyxia, 
without convulsions. The reflexes are diminished, but, according to 
Prevost, the knee-jerk does not disappear until after the pupillary and 
conjunctival reflexes, an indication that the action of the drug is upon 
the upper rather than upon the lower portion of the spinal cord. Par¬ 
aldehyde appears to have very little effect upon the circulation, though 
it has been shown by Quinquand that after large doses there is lessening 
of the heart-force. In poisoning by it the bodily temperature falls, the 
elimination of carbonic acid is lessened, and the color of the blood is 
changed. According to Quinquand, this change of the blood-color is due 
to methfemoglobin, but Henocque affirms that the spectroscope shows 
only the band of reduced lnemoglobin, and that paraldehyde checks 
the formation of methaemoglobin in poisoning by the nitrites. 

Therapeutic Properties. —Physiological researches upon paralde¬ 
hyde have led to its employment in practical medicine as a hypnotic 
with the hope that it would be superior to chloral. When taken in 
doses of one drachm it usually produces sleep closely resembling natural 
sleep, which may not be followed by after-effects. Paraldehyde is, 
however, very irritant to mucous membranes, and therefore not rarely 
impairs the digestion, and Dr. J. Gr. Kiernan has found its prolonged 
use to be followed by intractable nasal ulcers, skin-eruptions, and 
other evidences of disturbance of nutrition, such as occur after the 
similar employment of chloral, while Kraft-Ebing has seen delirium 
and other outward results, and also a paraldehyde habit. Dr. H. B. 
Williams (Journ. Arner. Med. Assoc., vol. viii.) states that he has used it 
with success in epilepsy. In therapeutic doses it has little or no control 
over pain. It must be always given well diluted. One objection to it 
is the disagreeable odor which it is apt to impart to the breath. Dr. 
Sommer (Neurolog. Centralbl., 1886) reports a case in which severe vaso¬ 
motor disturbance was an after-effect of paraldehyde. Prof. Bokai 
(Pharm. Post, April, 1886) found it in animals the physiological antidote 
of strychnine; and Kraft-Ebing used it successfully, in doses of three 
drachms a day, in spinal accessory spasm (Zeitschr.f. Therap., April, 1887). 

Amylene Hydrate is a clear, colorless liquid, of a penetrating odor, 
soluble in eight parts of water, and miscible with alcohol in almost all 
proportions, whose physiological properties were discovered in 1885 by 
Yon Mei'ing and. Thierfelder ( Zeitschr. f. Phys. Chemie., Bd. 1. S. 9). 
According to Yon Mering, it is a valuable hypnotic, standing midway 
between chloral hydrate and paraldehyde, one drachm of chloral, two 


S0MN1FA Cl ENTS. 


195 


drachms of amylene hydrate, and three drachms of paraldehyde being 
about equivalent in power. In moderate doses it is said to produce in 
the lower animals deep sleep without affecting the respiration or circula¬ 
tion. Large doses paralyze the medulla oblongata. Yon Mering has 
used amylene hydrate in doses of from fifty to ninety drops in sixty 
cases of insomnia with excellent results. It is preferable to paralde¬ 
hyde on account of its more pleasant taste. In sleeplessness from pain 
it has little or no influence. 

Urethan is chemically carbamate of ethylic ether. It occurs in 
crystals or crystalline masses, without odor, and having a taste like salt¬ 
petre. It is soluble in one part of water, six-tenths parts of alcohol, 
one part of ether, one and three-tenths parts of chloroform, and three- 
tenths part of glycerin. The watery solution has a neutral reaction. 
Attention was first called to it as a possible hypnotic by Professor 
Schmiedeberg ( Archiv f. Exper. Path. Pharm xx. 210), and it has 
since been physiologically investigated by Jacksch ( Wien. Med. Blatter , 
1885) and by Professor Yon Anrep (. London Med. Pec., Dec. 15, 1886). 
When urethan is given to one of the lower animals it produces first a 
period of excitement, with increased respiration and cardiac movements, 
which is followed very shortly by a deep sleep, with slowing of the 
respiration. If a fatal dose has been taken, the respiration becomes 
slower and slower, the unconsciousness absolute, the reflexes are abol¬ 
ished, and a pronounced fall of the bodily temperature occurs, with 
marked weakness of the cai'diac action, and finally death from asphyxia. 
According to Schmiedeberg, the action of urethan upon the circulation 
is very slight, much less than that of chloral; even in deep narcosis 
the arterial pressure remaining normal. The lessening of reflex activity 
is primarily due to an action upon the spinal cord, although the irrita¬ 
bility of the peripheral endings of the motor nerves is said to be 
lessened. The psycho-motor centres in the cerebral cortex, according 
to Yon Anrep, suffer decrease of their faradic excitability under the 
influence of decided doses. Urethan has been used to a considerable 
extent by clinicians as a hypnotic, but the reports as to its action are 
very contradictory. Thus, it is commended by Dr. Sticker ( Deutsches 
Med. Zeitschr., Jan. 1886), by Dr. Myrtel (Brit. Med. Journ., Feb. 1886), 
by Dr. Rottenbiller ( Therap. Gaz., ii. 474), and by Dr. Kraepelin (Neurol. 
Centralbl., No. 5, 1886), while Dr. Bock and Dr. W. Koenig condemn it. 
It has been used hypodermically by Koenig in doses of as high as 
twenty-one grains without success. By the mouth, according to Kraepe¬ 
lin, a full dose is forty-five grains, but seventy-five grains may be given. 
It appears to have no analgesic effect. It has been given by Jackman 
(Lancet, June, 1886) in traumatic tetanus with success after the failure 
of chloral (a boy aged fifteen, four grains every two hours); and by 
Dr. T. S. Bennett with asserted advantage in the eclampsia of child¬ 
hood and of the puerperal state (Trans. Texas State Med. Assoc., 1887). 


196 


GENERAL REMEDIES. 


Hypnone, or Acetophenone, is a colorless, volatile liquid, having a 
very tenacious, persistent odor, recalling that of bitter almonds, not in¬ 
flammable, not soluble in water or in glycerin, but very soluble in alcohol, 
ether, chloroform, benzin, and also certain oils, especially that of sweet 
almonds. It was first proposed as a hypnotic by Dr. Dujardin-Beau- 
metz, who states that in the lower animals it causes deep sleep. M. 
Laborde ( Compt.-Rend. Soc. Biol., 1885) affirms, however, that it does 
not produce in the lower animals deep sleep unless given in toxic doses, 
when the unconsciousness terminates in death from asphyxia. He also 
states that it has a powerful local paralyzant influence. Professor Grasset 
(,Semaine Med., Dec. 1885) likewise failed to obtain a hypnotic influence, 
either by hypodermic or stomachic administration, in dogs and monkeys, 
and Mairet and Combemale (. Montpellier Med., vol. xviii., 1886) also find 
that its narcotic power varies in different animals, and that the para¬ 
lytic is usually greater than the soporific influence. After fatal doses, 
coma, general muscular paralysis, and death from asphyxia result. The 
reports of clinicians upon the action of hypnone generally condemn 
it. Kraepelin, it is true, speaks of it as a useful remedy, and Dr. C. 
Norman ( Journ. Merit. Sci ., vol. xxxii. p. 519) has successfully used it 
hypodermically, in doses of five to twelve minims, in various cases of 
insanity; but Hirt, Mairet and Combemale, Key, and Eottenbiller have 
all failed to obtain good results from it. The maximum dose given by 
Key without success was sixty drops, or twenty-three grains. 

Methylal is a highly volatile fluid, boiling at 107.60, soluble in water, 
alcohol, and oil. Prepared chemically by Malaguti in 1839, it was not 
suggested as a medicine until 1887, when M. Personali discovered that 
it causes in the lower animals sleep, with increase of the pulse-rate and 
lowered arterial pressure and temperature. It has been further studied 
by Dr. M. Motrokhin ( Vratch, x., 1887, abstracted Brit. Med. Journ., vol. 
i., 1887), who finds that it lessens reflex activity and the irritability of 
the cerebral cortex, and when inhaled by man in doses of two ounces 
produces sleep, with loss of sensibility, without any effect upon the 
heart. But Dr. Serges Popoff (Ibid.) states that according to his re¬ 
searches it acts directly upon the cardiac muscle or its ganglia, both in 
frogs and in warm-blooded animals. It is rapidly absorbed and very 
rapidly eliminated, and ought perhaps to be considered as an anaesthetic 
rather than a hypnotic. It has been given hypodermically, but Mo¬ 
trokhin affirms that its subcutaneous injection is very painful and often 
causes local gangrene. Mairet and Combemale ( Compt.-Rend., Jan. and 
April, 1887) have used methylal in thirty-six cases of insanity. Their 
commencing dose is seventy-five grains, their maximum dose one hun¬ 
dred and twenty grains. Its use is said to be free from danger and to 
cause no unpleasant after-effect; but most patients become rapidly accus¬ 
tomed to it, so that its sleep-producing power is greatly impaired. 


FAMILY IV-DELIRIFACIENTS. 


In the present group are considered medicines whose preparations, 
when taken into the system, cause marked dilatation of the pupil, and 
act upon the cerebral nerve-cells so as to produce delirium. 

CANNABIS INDICA—INDIAN CANNABIS—INDIAN HEMP. 
U.S. CANNABIS AMERICANA—AMERICAN CANNABIS. 

U.S. 

Under the respective names which head this article, the U.S. Phar¬ 
macopoeia recognizes the dried tops of the Cannabis sativa, or common 
hemp plant, as it grows in India and in our own country. 

EXTRACTUM CANNABIS INDICT—EXTRACT OF INDIAN HEMP. 

U.S. 

The alcoholic extract of Indian hemp is a blackish, resinous extract, 
of a decided narcotic odor and a peculiar taste. J n the East, hemp and 
its educts are used as narcotic stimulants. Gunjah is the dried plant as 
sold in the bazaars of Calcutta for smoking. Churrus is the resinous 
exudation with the epidermis, etc., scraped off the leaves. Hashish is 
an Arabian preparation of the drug. The resin, which represents the 
activity of hemp, is sometimes known as Cannabine. It is best obtained 
by precipitating the saturated tincture with water containing an alkali. 
Hemp also contains a trace of volatile oil. 

Physiological Action. —When given in full doses, cannabis indica 
produces a feeling of exhilaration, with a condition of revery, and a 
train of mental and nervous phenomena which varies very much ac¬ 
cording to the temperament or idiosyncrasies of the subject, and very 
probably also, to some extent, according to the nature of his surround¬ 
ings. The sensations are generally spoken of as very pleasurable; 
often beautiful visions float before the eyes, and a sense of ecstasy fills 
the whole being; sometimes the venereal appetites are greatly excited; 
sometimes loud laughter, constant giggling, and other indications of 
mirth are present. Some years since, in experimenting with an extract 
made from the American plant, I took a large dose, and described the 
result as follows ( Proceed . Amer. Philosoph. Soc., 1869, vol. xi. p. 226): 

“About half-past four p.m., September 23, I took most of the ex¬ 
tract. No immediate symptoms were produced. About seven p.m. a 
professional call was requested, and, forgetting all about the hemp, I 
went out and saw my patient. While writing the prescription, I be- 

197 



198 


GENERAL REMEDIES. 


came perfectly oblivious to surrounding objects, but went on writing, 
without any check to or deviation from the ordinary series of mental 
acts connected with the process, at least that I am aware of. When 
the recipe was finished, I suddenly recollected where I was, and, look¬ 
ing up, saw my patient sitting quietly before me. The conviction was 
irresistible that I had sat thus many minutes, perhaps hours, and 
directly the idea fastened itself that the hemp had commenced to act, 
and had thrown me into a trance-like state of considerable duration, 
during which I had been stupidly sitting before my wondering patient. 
I hastily arose and apologized for remaining so long, but was assured 1 
bad only been a very few minutes. About seven and a half p.m. I re¬ 
turned home. I was by this time quite excited, and the feeling of hilarity 
now rapidly increased. It was not a sensuous feeling, in the ordinary 
meaning of the term; it was not merely an intellectual excitation; it 
was a sort of bien-etre ,—the very opposite to malaise. It did not come 
from without; it was not connected with any passion or sense. It was 
simply a feeling of inner joyousness; the heart seemed buoyant beyond 
all trouble; the whole system felt as though all sense of fatigue were 
forever banished; the mind gladly ran riot, free constantly to leap from 
one idea to another, apparently unbound from its ordinary laws. I 
was disposed to laugh; to make comic gestures; one very frequently re¬ 
current fancy was to imitate with the arms the motions of a fiddler, 
and with the lips the tune he was supposed to be playing. There was 
nothing like wild delirium, nor any hallucinations that I remember. 
At no time had I any visions, or at least any that I can now call to 
mind; but a person who was with me at that time states that once I 
raised my head and exclaimed, ‘ Oh, the mountains! the mountains!’ 
While I was performing the various antics already alluded to, I knew 
very well I was acting exceedingly foolishly, but could not control my¬ 
self. I think it was about eight o’clock when I began to have a feeling 
of numbness in my limbs, also a sense of general uneasiness and unrest, 
and a fear lest I had taken an overdose. I now constantly walked 
about' the house; my skin to myself was warm, in fact my whole sur¬ 
face felt flushed ; my mouth and throat were very dry; my legs put on 
a strange, foreign feeling, as though they were not a part of my body. 
I counted my pulse and found it one hundred and twenty, quite full 
and strong. A foreboding, an undefined, horrible fear, as of impending 
death, now commenced to creep over me; in haste I sent for medical 
aid. The curious sensations in my limbs increased. My legs felt as 
though they were waxen pillars beneath me. I remember feeling them 
with my hand and finding them, as I thought at least, very firm, the 
muscles all in a state of tonic contraction. About eight o’clock I began 
to have maxlced ‘spells,’—periods when all connection seemed to be 
severed between the external world and myself. I might be said to 
have been unconscious during these times, in so far that I was oblivious 
to all external objects, but on coming out of one it was not a blank, 


DELI RIF A Cl ENTS. 


199 


dreamless void upon which I looked back, a mere empty space, but 
rather a period of active but aimless life. I do not think there was 
any connected thought in them; they seemed simply wild reveries, 
without any binding cord,—each a mere chaos of disjointed ideas. The 
mind seemed freed from all its ordinary laws of association, so that it 
passed from idea to idea, as it were, perfectly at random. The duration 
of these spells to me was very great, although they really lasted but 
from a few seconds to a minute or two. Indeed, I now entirely lost 
my power of measuring time. Seconds were hours; minutes were 
days; hours were infinite. Still, I was perfectly conscious during the 
intermissions between the paroxysms. I would look at my watch, and 
then after an hour or two, as I thought, would look again and find that 
scarcely five minutes had elapsed. I would gaze at its face in deep dis¬ 
gust, the minute-hand seemingly motionless, as though graven in the 
face itself; the laggard second-hand moving slowly, so slowly. It ap¬ 
peared a hopeless task to watch during its whole infinite round of a 
minute, and always would I give up in despair before the sixty seconds 
had elapsed. Occasionally, when my mind was most lucid, there was 
in it a sort of duplex action in regard to the duration of time. I would 
think to myself, It has been so long since a certain event,—an hour, for 
example, since the doctor came; and then reason would say, No, it has 
been only a few minutes; your thoughts or feelings are caused by the 
hemp. Nevertheless, I was not able to shake off this sense of the 
almost indefinite prolongation of time, even for a minute. The parox¬ 
ysms already alluded to were not accompanied with muscular relaxa¬ 
tion. About a quarter before nine o’clock, I was standing at the door, 
anxiously watching for the doctor, and when the spells would come on 
I would remain standing, leaning slightly, perhaps, against the door-way. 
After a while I saw a man approaching, whom I took to be the doctor. 
The sounds of his steps told me he was walking very rapidly, and he 
was under a gas-lamp, not more than one-fourth of a square distant, 
yet he appeared a vast distance away, and a corresponding time ap¬ 
proaching. This was the only occasion on which I noticed an exaggera¬ 
tion of distance; in the room it was not perceptible. My e-xtremities 
now began to grow cold, and I went into the house. I do not remember 
further, until I was aroused by the doctor shaking or calling me. Then 
intellection seemed pretty good. I narrated what I had done and 
suffered, and told the doctor my opinion was that an emetic was indi¬ 
cated, both to remove any of the extract still i*emaining in my stomach, 
and also to arouse the nervous system. I further suggested our going 
into the office, as more suitable than the parlor, where we then were. 
There was at this time a very marked sense of numbness in my limbs*, 
and what the doctor said was a hard pinch produced no pain. When 
I attempted to walk up-stairs, my legs seemed as though their lower 
halves were made of lead. After this there were no new symptoms, 
only an intensifying of those already mentioned. The periods of un- 


200 


GENERAL REMEDIES. 


consciousness became at once longer and more frequent, and during 
their absence intellection was more imperfect, although when thoroughly 
roused I thought I reasoned and judged clearly. The oppressive feel¬ 
ing of impending death became more intense. It was horrible. Each 
paroxysm would seem to have been the longest I had suffered; as I 
came out of it, a voice seemed constantly saying, ‘ You are getting 
worse; your paroxysms are growing longer and deeper; they will over¬ 
master you; you will die.’ A sense of personal antagonism between 
my w T ill-power and myself, as affected by the drug, grew very strong. 
I felt as though my only chance was to struggle against these parox¬ 
ysms,—that I must constantly arouse myself by an effort of will; and 
that effort was made with infinite toil and pain. I felt as if some evil 
spirit had control of the whole of me except the will-power, and was in 
determined conflict with that, the last citadel of my being. I have 
never experienced anything like the fearful sense of almost hopeless 
anguish and utter weariness which was upon me. Once or twice during 
a paroxysm I had what might be called nightmare sensations: I felt 
myself mounting upwards, expanding, dilating, dissolving into the wide 
confines of space, overwhelmed by a horrible, rending, unutterable 
despair. Then, with tremendous effort, I seemed to shake this off, and 
to start up with the shuddering thought, Next time you will not be 
able to throw this off, and what then? Under the influence of an 
emetic I vomited freely, without nausea, and without much relief. 
About midnight, at the suggestion of the doctors, I went up-stah*s to 
bed. My legs and feet seemed so heavy I could scarcely move them, 
and it was as much as I could do to walk with help. I have no recol¬ 
lection whatever of being undi’essed, but am told I went immediately 
to sleep. When I awoke, early in the morning, my mind was at first 
clear, but in a few minutes the paroxysms, similar to those of the even¬ 
ing, came on again, and recurred at more or less brief intervals until 
late in the afternoon. All of the day there was marked anaesthesia of 
the skin. At no time were there any aphrodisiac feelings produced. 
There was a marked increase of the urinary secretion. There were no 
after-effects, such as nausea, headache, or constipation of the bowels.” 

The sense of prolongation of time which I experienced was to me 
very remarkable, but is not uncommon in these cases. It is evidently 
due to the immense rapidity of the succession of ideas. The mind, 
Avithout doubt, measures time by the duration of its own processes, and 
when an infinitude of ideas arise before it in the time usually occupied 
by a few, time becomes infinitely prolonged to the mind. It is a life¬ 
time in the minute. A \ T ery common mental phenomenon, not yet 
mentioned, is a condition of double consciousness, a sense of having 
two existences, of being at the same time one’s self and somebody else. 

In some cases Indian hemp produces, in addition to or even in the 
place of the symptom already spoken of, marked disturbances of mo¬ 
tility. Convulsions have been noticed by Dr. Lawrie ( Stille's Thera- 


DELIRIFA Cl ENTS. 


201 


peutics, vol. i. p. 772), and local spasms, with salaam convulsions, by 
Dr. F. H. Brown. According to Dr. O’Shaughnessy, the induction of 
catalepsy is not rare among the Hindoos. 

Whatever may be the symptoms of the first stage, sooner or later, 
if the dose be sufficient, drowsiness comes on. Generally, before it is 
marked, partial anaesthesia, often with partial loss of strength, is mani¬ 
fested, especially in the lower limbs. The pupils are dilated, the pulse 
is quickened, and finally the subject falls into a heavy sleep, out of 
which he generally awakes hungry, without any of the wretched 
gastric sensations or the malaise felt after an opiate. Confusion of 
thought, however, may persist for some hours. Cannabis exerts no 
constipating influence upon the bowels, and appears to increase, rather 
than decrease, the excretion of the kidneys. 

In the lower animals cannabis indica produces symptoms some¬ 
what similar to those which it causes in man. In the dog there is a 
stage of exaltation followed by profound sleep (Hans Zeitler, Inaug. 
Diss., 1885; H. A. Hare, Therap. Gazette , 1887). That the drug has 
very little influence upon the vital functions is shown by the enormous 
amounts required in Dr. Hare’s experiments to kill. Dr. Hare noted 
both in the dog and in the frog that there was a period of heightened 
followed by one of markedly lessened reflex activity. The loss of 
reflex activity was the result of an influence exerted upon the sensory 
side of the cord or upon the sensory nerve trunk, the anaesthesia in the 
frog being complete at a time when voluntary movement was preserved: 
further, when the drug was applied directly to the nerve-trunk it pro¬ 
duced sensory palsy. Although probably a local anaesthetic, cannabis 
indica is too irritant to be applied to delicate mucous membranes. 

Therapeutics. —Leaving out of sight the employment of the medi¬ 
cine by alienists, hemp has been used in this country chiefly for the 
relief of pain, but also to some extent as a hypnotic. As an analgesic , 
it is very much inferior to opium, but may be tried when the latter is 
for any reason contra-indicated. In full doses, in neuralgic pains, it 
certainly often gives relief. It has been very largely employed to in¬ 
duce euthanasia in the advanced stages of phthisis , and constitutes, it is 
said, a popular nostrum employed for that purpose. In tetanus , Indian 
hemp has been used quite largely, and until within a short time was, 
after opium, one of the few known drugs of service. Dr. Roemer {St. 
Louis Medical and Surgical Journal , p. 363, 1873) has collected thirty- 
five cases, with twenty-one recoveries and fourteen deaths. As sug¬ 
gested by Dr. Seguin, of New York, cannabis indica is sometimes of 
value in the treatment of migraine. It should be given continuously, 
day after day, for months, in such doses as will keep just within the 
limit of distinct physiological effects. 

Administration. —The action of the preparations of Indian hemp 
is exceedingly variable, in some cases small doses producing alarming 
effects, in other instances the remedy seeming almost entirely power- 


202 


GENERAL REMEDIES. 


less. There appears to be a very great difference in the susceptibility 
of persons to its influence; but this cannot explain the wide variance 
of the clinical results obtained by its use. A large proportion of the 
extracts upon the market must be inert. Possibly the crude drug 
undergoes deterioration during its long sea-voyage from India; at 
least I have had extract carefully made from genuine Indian hemp 
and offering all the physical characters of good extract, yet entirely 
inert in doses of many grains. I have seen an eighth of a grain of an 
English extract produce in a susceptible woman decided intoxication. 
So far as my present knowledge goes, although the foreign extracts 
of hemp are often inefficient, they are much more reliable than the 
American. The only way of administering hemp with satisfaction at 
present is for the practitioner to try various samples until he gets an 
active one, and then, being supplied with this, and having learned its 
proper dose by clinical experiment, to depend solely upon it. Hemp is 
not a dangerous drug; even the largest doses of its active prepara¬ 
tions, although causing most alarming symptoms, do not compromise 
life. No case of acute poisoning by it terminating fatally has, that I 
am aware of, been reported. The dose of the officinal tincture ( Tinctura 
Cannabis Indicce , U.S.) is thirty minims; of the fluid extract (Extractum 
Cannabis Indicce Fluidum, U.S.) one minim. 

Under the name of tannate of cannabene the German chemist Merck 
has put upon the market a preparation of cannabis, which is affirmed 
by Fronmiiller ( Memorabilien , 1882, 257) and by Hiller ( Berlin . Klin. 
Wochenschr., 1883, ix. 125) to be a very valuable mild hypnotic in doses 
of from four to seven grains. Fronmiiller believes that the failure of 
others to obtain similar results is largely due to the use of insufficient 
doses. In some trials which I made of it it seemed to be entirely inert. 

BELLADONNA FOLIA—BELLADONNA LEAF. U.S. 

BELLADONNA RADIX-BELLADONNA ROOT. U.S. 

The leaves and root of Atropa Belladonna, an herbaceous perennial, 
a native of Europe, but cultivated in this country, and attaining a 
height of some three feet. The oval, pointed, entire, smooth, unequal 
leaves ai’e in pairs, on a short footstalk. The bell-shaped, axillary, pen¬ 
dent flowers are of a dull reddish color. The globular berry is about 
three-quarters of an inch in diameter, deep purple, with a violet-colored 
juice and adherent green calyx. The dried leaves have a faint nar¬ 
cotic odor, and a sweetish, sub-acrid, slightly nauseous taste. The dried 
cylindrical branched root is from one to several inches in diameter, 
much longer, fibrous, externally reddish brown, internally whitish, 
almost odorless, with a very feeble sweetish taste. 

ATROPINA. U.S. 

The sole active principle of belladonna, discovered by Mein in 1831 
and independently by Geiger and Hesse in 1833, occurs in silky pris- 


DELI RIF A Cl ENTS. 


203 


matic and acicular, often aggregated crystals, of a bitter, burning taste, 
without odor, soluble in three hundred parts of cold and fifty-eight of 
boiling water, forty of benzole, thirty of ether, three of chloroform, 
and eight of alcohol. It is most abundant in the root, and, according 
to M. Lefort (L’ Union Med., Nov. 1871), in that of young plants. 
Cyanogen gas passed through its alcoholic solution makes a deep red 
(Hinterbeyer). The most reliable test is the physiological one,— i.e., 
the production of mydriasis in a rabbit or a cat by the local application 
to the eye. It has been found in all the tissues of poisoned individuals, 
but always exists in greatest abundance, and is most easily demon¬ 
strated, in the urine.* 

Physiological Action.— When the smallest physiological dose of 
atropine is administered to man, the only symptom induced is dryness 
of the throat and mouth, and possibly some disorder of vision. When 
a little larger amount is given, this dryness is more intense, and is asso¬ 
ciated with redness of the fauces, dilated pupils, disordered vision, and 
possibly diplopia. The pulse is sometimes at first rendered less fre¬ 
quent, but this decrease is very transient, and certainly in many cases 
cannot be demonstrated at all. Often from the first, certainly after a 
short time in all cases, the heart’s beats, after a large dose of the alka¬ 
loid, become excessively rapid, the pulse rising to one hundred and 
twenty, or even one hundred and sixty; and in a little while a peculiar 
bright-red flush appears on the face and neck, and may spread over the 
whole body. As I have seen this, it lacks the punctations of the rash 
of scarlet fever, and is only in very severe cases followed by desquama¬ 
tion. 

Early in the course of the symptoms of atropine-poisoning there 
is very often forcible expulsion of urine, and erections of the penis 
may occur ; but afterwards there is very generally, Harley says always 
(Old Vegetable Neurotics , p. 207), retention of urine. With the symp¬ 
toms above enumerated, intellection may remain perfect; but there is 
generally some lightness of head, giddiness, and confusion of thought, 
as well as a staggering gait and restlessness. Occasionally, even with 
doses which may be called medicinal, there are spectral illusions. 
Drowsiness is not a general or at all characteristic symptom: if pres¬ 
ent, it is apparently always produced indirectly, as by the removal of 
some cause of previous wakefulness. When a decidedly poisonous 
amount of belladonna or its alkaloid has been taken, all the symptoms 
already noted are intensified, and to them is added a peculiar talkative, 
wakeful delirium, in which the patient lives in a world of his own, 
engrossed by the spectres and visions which throng him, and com¬ 
pletely oblivious to the surrounding realities. Thus, I have seen a lady 
remain for a long time stooping and holding fast to the bed-post, to 


* For a chemico-phvsiological study of tropine and other derivatives from atropine, see 
Arcliiv f. Exper. Pathol, u. Pliarm., v. 403. 



204 


GENERAL REMEDIES. 


which she talked in the most voluble manner, as though it were an 
intelligent living entity. Sometimes this delirium is wild, and the 
patient almost uncontrollably violent. After a time, sleep may come 
on, and on waking from this complete consciousness may be regained, 
or the symptoms may gradually subside. After a very large dose has 
been taken, severe convulsions may appear in a very short time, and 
persist, with or without furious maniacal delirium, until near death. 
Sooner or later, however, the delirium subsides into stupor, and the 
convulsions into paralysis; and when the dose has been enormous, and 
especially when the alkaloid itself has been taken, stupor, with great 
muscular relaxation, may occur very early. Lividity of the face, and 
evident imperfect aeration of the blood, are not seen in atropine-poison¬ 
ing, except in the stage of most imminent peril. Death is preceded by 
marked failure both of the heart’s action and of the respiratory forces. 
In most cases, I think, it is actually brought about by asphyxia.* 
Post-mortem examinations have shown in fatal eases congestion of the 
lungs, often with ecchymoses, and a similar state of the membranes 
and even substance of the brain and cord. * According to M. Lemattre,f 
congestion of the retina is an almost characteristic lesion of atropine¬ 
poisoning. 

Upon the lower animals belladonna to a great extent acts as upon 
man, although its influence is much less powerful in them, and very 
much larger doses are inquired. Seeming differences of action are in 
most cases simply apparent, not i-eal. Thus, in the dog, as in man, the 
pulse-i'ate is very gi’eatly inci’eased by atropine, while in the i*abbit it 
is not. As will be shown hereafter, the rise of the pulse-rate in the 
former is largely due to paralysis of the par vagum. Atropine para¬ 
lyzes the par vagum in the rabbit as much as in the dog, but in the 
rabbit pneumogastric paralysis, by section or othemvise, is never fol¬ 
lowed by a rise of the pulse-rate at all comparable to that seen under 
similar circumstances in the dog. Evidently the action of the drug is 
identical in the two cases, although the symptoms are different. In 
their sensitiveness to atropine animals differ veiy much, and, as a 
general rule, herbivora are less susceptible than carnivoi’a. Thus, the 
rabbit may be fed for days entirely upon belladonna-leaves without 
injury, and many grains of atropine are necessai-y to kill him. Birds 
—at least pigeons—I have found will often recover after the lypoder- 
mic injection of two gi'ains of atropine, and three gi’ains by the mouth 
did not pi’ove fatal. A very curious and at present inexplicable fact, 
which I have repeatedly vei'ified, is that the pupils in pigeons cannot 
be dilated by the use of belladonna. 

The close study of the physiological action of atropine can only be 


* See a case reported by S. W. Gross, Amer. Journ. Med. Sci., 1869, p. 401, as a striking 
instance. 

f Quoted by Tardieu, Sur V Empoiaonnement, Paris, 1867, p. 752. 



DELIRIFA Cl ENTS. 


205 


made system by system, and I shall now consider the subject under 
such headings. 

Action on the Circulatory System* —In the dog and in the rabbit 
small doses of atropine cause an increased frequency of the pulse, with 
rise of the arterial pressure. If, however, larger amounts of the alka¬ 
loid are used, and especially if the poison is thrown immediately into 
the venous circulation, there is an immediate fall of the blood-pressure, 
although the pulse increases as before. Bezold and Bloebaum ( Unter- 
such. aus d. Physiolog. Lahorator. in Wurzburg, Heft i.) state that the 
dose of atropine can be so graduated as to produce at first a temporary 
rise of the arterial pressure, followed in a short time by a fall. 

In atropinized animals, as is stated both by Bezold and Bloebaum 
(loc. cit., p. 33) and by Meuriot (He la Methode physiol, en Therap. et de ses 
Applications a VEtude de la Belladone , Paris, 1868, p. 73), and as I have 
frequently seen, section of the vagi is not followed by any increase of 
the heart’s action, and galvanization of the nerve is incapable of influ¬ 
encing the viscus. It follows that atropine in toxic doses paralyzes 
either the trunk or the peripheral filaments of the nerve, and, as Be¬ 
zold and Bloebaum believe, most probably the latter. The observers 
just named have found that if atropine be injected into the carotid so as 
to reach the pneumogastric centres before the periphery, there is an 
instantaneous fall in the rate of the heart’s beat,—an indication that 
upon the cardiac inhibitory centres atropine acts as a direct stimulant, 
precisely as it does on the spinal cord, the reason that the action is not 
more manifest under ordinary circumstances being the incapacity of 
the paralyzed vagus to transmit the central impulse. This asserted 
stimulationf of the inhibitory centre, if it be correct, accounts very 
beautifully for the primary brief slowing of the pulse stated to occur 
in some cases of atropine-poisoning. (See Stilles Therapeutics, vol. i. 
p. 725. Mitchell, Keen, and Morehouse found it in about one-third of 
the cases after large hypodermic injections; Da Costa in a large pro¬ 
portion, Amer. Journ. Med. Sci., July, 1865; and Miss Mary Putnam in 
some cases, New York Medical Record, 1873.) 

The reports as to the action upon the frog’s heart are somewhat at 


* A long paper upon Calabar bean and atropine has been published by Rossbach and 
Frohlich ( Verhandl. d. Wurzburger Phys.-Med. Gesells., 1873), in which results totally at 
variance with those of all other observers, and many of them as totally at variance with gen¬ 
eral physiological laws, have been reached. Space cannot be spared for a criticism of this 
paper, and the reader is referred to the memoir itself abstracted ( London Med. Rec., i.) and 
to the critique of Harnack {Archiv f. Exper, Pathol. Pharm., ii. 307). See also Pharma- 
kolog. Uiitersuch., Bd. i. Heft 3 and 4. 

■(■The experiments and conclusions of Rossbach and Frohlich confirm the existence of 
this stimulating action of atropine on the inhibitory centres, but cannot be received as cor¬ 
rect, for reasons already given. Harnack ( Archiv f. Exper. Pathol. Pharm., ii. 328) finds 
that the minutest dose of atropine increases the rapidity of the heart after stimulation of its 
inhibitory centres by muscarine and consequent slowing of its beat. This does not, however, 
prove that atropine has no action on the inhibitory centres. Further investigation is neces¬ 
sary for a positive conclusion. 



206 


GENERAL REMEDIES. 


variance, JBowditch and Luciani having noted an increase, Gnauck a 
lessening, in the cardiac pulsations ( Verhandl. Physiolog. Gesellsch. zu 
Berlin , 1881). H. Schapiro states that this variance is accounted for 
by the fact which he has discovered, that whereas at high tempera¬ 
ture (15° C.) the pulsations are diminished, at low temperature (7° C.) 
they are increased. The explanation of H. Schapiro does not, however, 
contain the whole truth : it appears to be certain that after large doses 
of atropine the frog’s heart suffers diastolic arrest and cannot be re¬ 
excited by galvanic or other stimuli; and Bezold and Bloebaum (loc. cit., 
p. 48) have found that the same thing occurs when an overwhelming 
dose of the alkaloid is injected into the jugular vein of a mammal. 
When, by the division of the spinal cord and vagi, the heart is isolated 
from the nerve-centres and the vaso-motor nerves are paralyzed, Bezold 
and Bloebaum have found that atropine lessens at once the arterial press¬ 
ure. Unfortunately, the smallest dose used by Bezold and Bloebaum 
was a grain and a half of atropine thrown directly into the torrent of 
the circulation, so that they cannot truly be said to have used minute 
doses, and the effect of such minute quantities upon the heart of the 
mammal after its isolation from the nervous system still remains un¬ 
known. It may be considered settled that large doses of atropine act 
as a direct paralyzant upon the heart-muscle. Minute quantities probably 
stimulate the muscle; thus, Bamson found that atropine causes in the 
heart of the octopus pronounced excitation of the muscular fibre; O. 
Langendorff ( Archiv fur Phys ., 1886) found that when the cut-off apex 
of the frog’s heart was touched with a minute quantity of atropine 
it immediately commenced to beat; and G. Beyer ( Amer . Journ. Med. 
Pci., July, 1885) noticed that the ventricles of the isolated terrapin’s 
heart are enormously stimulated by minute quantities of the alkaloid, 
although they are arrested in diastole by larger amounts. 

From what has already been said, it is evident that the increase of 
the pulse seen in atropine-poisoning is in a measure due to paralysis 
of the cardiac inhibitory nerves; but that this is not the only cause 
is shown by the fact noticed by Lemattre ( Archives Generates, August, 
1865) and confirmed by my own experiments, that after section of the 
par vagum atropine still causes an increase in the rapidity of the heart’s 
action. Further, Bezold and Bloebaum have found (loc. cit., p. 54) that 
when the thoracic sympathetic is galvanized, even after large doses of 
atropine, the heart is very sensibly affected. From these facts it is 
obvious that atropine acts on the cardiac accelerator nerve-centres, or 
possibly nerves , as a stimulant, and, unless it be in lethal doses, does not 
destroy the excitability of these nerves. 

The relation of belladonna to the vaso-motor nervous system is of 
such practical importance that it deserves the closest study. Brown- 
Sequard says positively that the drug has the power of exciting the 
muscular fibres of the arterioles; but, as he nowhere details the reasons 
for this opinion, I think little weight is to be attached to his statement. 


DEL I RIF A Cl ENTS. 


207 


In 1857, Wharton Jones, of England ( Med. Times and Gaz ., p. 28, 
1857), announced the fact (confirmed by Lemattre, loc. cit ., p. 52) that 
if atropine be dropped upon the web of a frog’s foot, under the micro¬ 
scope the vessels can be seen to contract. Dr. Hayden ( Dublin Quar¬ 
terly, Aug. 1863) in repeating these experiments found that if the skin 
were cut just above the foot, no contraction occuiTed, and concluded 
that the phenomenon was purely reflex. Meuriot (loc. cit., p. 39) has 
obtained in some cases, but not invariably, the results of the last ob¬ 
server. He has, however, discovered that if the nerves of the leg be 
divided, no contraction ever takes place. Atropine is an irritant, and 
it is evident that the contraction caused by its local application is 
simply, as Hayden believed, a reflex phenomenon, precisely similar to 
that which occurs on the application of any chemical or mechanical 
irritant. The experiments of Wharton Jones, upon which so much 
has been based, must, therefore, be eliminated from the evidence on 
the question. The problem can be solved only by studying the effects 
of the remedy administered so as to act on the part solely through 
the circulation. Meuriot, as the result of such studies on the frog’s 
web, has concluded that there is in the first stages of the poisoning a 
very slight contraction of the vessels, amounting to nothing more than 
increase of their tonicity, never to any decided lessening of their 
lumen. Dr. Harley (The Old Vegetable Neurotics, London, 1869, p. 
220) has witnessed a more decided contraction of the vessels. I have 
tried the experiment several times, but obtained no decided results. 
On the other hand, Bezold and Bloebaum (loc. cit., p. 50) have made 
similar experiments upon the ear and mesentery of the rabbit, and 
have never been able to detect any contraction of the vessels, and 
consequently deny its existence. In these experiments it was not pos¬ 
sible to use the microscope,—which detracts greatly from their value. 

The evidence derived from direct observation of the capillaries 
seems to me to be, on the whole, decidedly in favor of their contrac¬ 
tion by minute doses of belladonna. I do not think, however, that 
much weight is to be attached to evidence of this nature. The altera- 
tions in the calibre of the vessels are so slight as to leave great play for 
the imagination of the observer,—a source of fallacy which probably 
accounts for the different results obtained by different investigators. 
Much more decisive proof is, however, obtainable from a study of 
the arterial pressure. I have found that after section of the vagi 
atropine still has the power of raising very materially the arterial 
pressure. As atropine does not augment the force of the individual 
cardiac beat, and as the increase in the number of the cardiac pulsa¬ 
tions caused by it after section of the vagi is comparatively slight, it is 
exceedingly probable that the rise of arterial pressure just spoken of 
is due to a contraction of the small vessels. This logical conclusion 
becomes almost a certainty when it is further known that after division 
of the cord, and consequent separation of the vessels from their vaso- 


208 


GENERAL REMEDIES. 


motor centres, atropine is powerless to produce rise of arterial press¬ 
ure, a fact vouched for by Bezold and Bloebaum, and which f can 
confirm from my own experiments (Amer. Journ. Med. Sci., April, 
1873). To this cumulative evidence must be added the experimental 
fact noted by Bezold and Bloebaum, that when a small dose of atro¬ 
pine is injected into the carotid artery— i.e., into the vaso-motor centres 
—there is an instantaneous rise of blood-pressure.* 

Viewing all these facts together, I am forced to give assent to the 
proposition that atropine, in not too large amount , is a stimulant to the 
vaso-motor centres; a conclusion in harmony with the action of the 
drug on all the other motor centres. All observers agree that in the 
advanced stage of atropine-poisoning, after the blood-pressure has com¬ 
menced to fall, there is dilatation of the capillaries. It seems most 
probable that this is due to a direct action of the poison on the muscu¬ 
lar fibres in the coats of the vessels; for when directly applied to the 
web of the frog’s foot, atropine, after a time, produces an evidently 
paralytic dilatation; and Bezold and Bloebaum have found that the arte, 
rial muscular coats in atropine-poisoning finally lose their irritability, 
but that so long as they retain it, galvanic stimulation of a sympathetic 
nerve does not fail to induce contraction in the tributary vessels. 

Action upon the Nervous System .—The delirium which is so charac¬ 
teristic of atropine-poisoning shows that it has especial relations with 
the cerebral cortex. Professor Albertoni has made a series of experi¬ 
ments to determine whether it inhibits or affects the motor powers of 
the cortex. He finds that neither the single large dose nor the re¬ 
peated continuous dose has any power in preventing the epileptic 
seizure resulting in dogs from the stimulation of the motor zone of 
the cortex: enormous toxic doses seem only to render the response 
slower and less vivid (Arch. f. Exper. Path. Pharm., xv. 265). 

In 1862, Dr. S. Botkin ( Virchow's Archiv, xxiv. 85) found that 
when the vessels of a frog’s leg were tied and the animal poisoned 
with atropine, while paralysis developed itself in the ordinary way in 
the uninjured leg, the injured leg preserved its motility. He also dis¬ 
covered that the nerve of the leg whose artery had been tied trans¬ 
mitted a forcible impulse to its tributary muscles under the stimulus of 
a galvanic current much weaker than could elicit the faintest response 
from the nerve of the opposite side. He concluded, very logically, that 
atropine acts as a paralyzant to the motor nerve-trunks themselves, 
and also, since motion persisted in the protected leg after it was com¬ 
pletely lost in its fellows, that this influence of the drug was exerted 
upon the motor trunks before the spinal centres. These experiments 
have been confirmed by Lemattre (loc. cit., p. 49), by Bezold and Bloe¬ 
baum ( loc. cit., p. 20), by Meuriot (loc. cit., p. 90), and by Fraser and 


* It is proper to state that Bezold and Bloebaum attribute this rise to psychical disturb¬ 
ance, without, however, as it seems to me, good reason. 



DELI RIF A Cl ENTS. 


209 


others, who have proved that atropine, if in sufficient dose, has the 
power of destroying the excitability of the efferent or motor-nerve fibres , 
but that it must be in very large quantity, so that in mammals death 
may be caused by the alkaloid and yet a notable amount of functional 
power be retained by the motor nerves. Bezold and Bloebaum, whose 
elaborate experiments are especially commendable, affirm that very 
rarely have the} r been able totally to destroy by atropine the functional 
power of the motor nerves, and also have shown that both the nerve- 
stem and the peripheral intra-muscular nerve-endings are affected. All 
the experimenters agree that no stage of super-excitability preceding 
that of depression can be discovered. 

Professor Thos. R. Fraser discovered in 18G9 (Trans. Roy. Soc. 
Edinb ., xxv. 450) that if a frog receive an injection of about one- 
thousandth part of its weight of atropine, a condition of perfect 
paralysis and abolition of reflex action comes on after a time, and lasts 
from two to four days, to be succeeded by a tetanic stage, with violent 
convulsions and excessive excitability of the reflex centres. The con¬ 
vulsions of this stage have been shown by Fraser to be spinal, occurring 
after section of the cord in all parts of the body. Dr. Fraser found 
(Exp. 59, p. 481) that when he protected the hind legs by tying the 
aorta at its bifurcation, tetanus appeared in them at a time when the 
anterior legs were completely paralyzed and the brachial neiwes were 
unable to respond to the galvanic stimulation. Again, he was able to 
produce symptoms closely analogous to those caused by atropine by 
injecting simultaneously two poisons,—one a stimulant to the cord, the 
other a paralyzant of the nerve-trunks. These facts would seem to 
prove that during the paralytic stage of the action of atropine a con- 
vulsant condition of the cord is masked by a paralyzed state of the 
efferent nerves. This conclusion is, however, invalidated by certain 
facts observed by Fraser, and especially by the recent researches of 
Ringer and Murrell. Thus, in some of Fraser’s experiments the paraly¬ 
sis was at no time sufficient to mask a tetanus; in experiments of all 
three observers the tetanus did not develop at once in parts in which 
the nerve-trunks were protected by cutting off their blood-supply; con¬ 
trary to the observation of Frasei*, in a number of experiments per¬ 
formed by Ringer and Murrell, after the aorta had been tied tetanus 
developed no earlier in the protected than in the unprotected leg. In 
some of the experiments of Ringer and Murrell the paralyzant effect 
of the poison passed off—voluntary and reflex action returning—before 
the supervention of the tetanus. These facts seem to show that the 
paralysis as well as the tetanus is due to an action upon the centres, 
the drug so acting upon the spinal cord as first to abolish and then in¬ 
tensify its reflex activity. The explanation of this singular action can¬ 
not at present be considered as established. Drs. Ringer and Murrell 
believe that both the paralysis and the tetanus are due to a depressant 
action. The theory is that the normal cord has a power of resisting 

14 


210 


GENERAL REMEDIES. 


impulses received from the periphery, and especially of preventing their 
wide propagation among the spinal centres. During the first stage of 
the atropine-poisoning it is supposed that the motor portions of the 
cord are so paralyzed as to be unable to form or propagate any motor 
impulse, and hence the general paralysis. Later on, however, the motor 
cells have so far recovered themselves as to be able to generate im¬ 
pulses freely, although the resistive power of the cord is still in abey¬ 
ance. Consequently a peripheral impulse plays as it were at will up 
and down the spinal cord, and, instead of giving rise to a simple reflex 
action, gives origin to a series of reflex movements, involving all tho 
muscles, and constituting a tetanic convulsion. 

The experiments of Lemattre ( loc. cit.') indicate that belladonna 
exerts a similar paralyzant and convulsant action in mammals, and Dr. 
Fraser’s investigation confirms this. It would seem, however, that in 
mammals the convulsant action comes on more rapidly and is less pro 
tracted, and that the paralyzant action is also less intense, than in the 
frog; so that while the batraehian poisoned by atropine is in the be¬ 
ginning paralyzed and afterwards convulsed, the mammal sutlers from 
convulsions and reflex spasms early in the poisoning, and often exhibits 
evidences all through of the excited reflex activity. The difference in 
the action of non-fatal doses of atropine upon the frog and upon the 
mammal is graphically expressed by the diagrams, Figs. 9 and 10, from 
the paper of Dr. Fraser. 

Fig. 9 represents an experiment made upon a dog: in it the curve 
of paralysis, op, p 2 , leaves the line of normality, AB, before the curve 
of spinal stimulation, the first symptoms being those of paralysis. As 
the curve of op, p 2 never reaches the line of complete paralysis, CD, 
the paralytic action is not sufficiently great, in the height of the poison, 
to prevent the manifestation of the considerable spinal stimulant action. 


Fig. 9. 


c 


D 



7* 

7*- 

j?-—- T « 


1 

— . 



"*.TO 

-PS 

;pc P 

• i 


"To' 

■ti 

12 13 

A 

is 

re A 

ts 

lo 

m tn 

(T 1 






Fig. 10. 














D 




_.PS 









.. 

is 

-LS£ 

-Sit 

. 

. 

79* 

A 0 ' 


F+ 

ts 


... „ 

tu 


lio 

i r 


Fig. 10 expresses the results of an experiment upon a frog: in it, 
although there was some spinal stimulant action, as evinced by the 
curve s 4 , s 8 , s, 2 , s 16 , and although the paralytic curve p 4 , p 8 , p 12 , p 16 , p 20 never 
reaches the line of complete paralysis, CD, yet it is manifest that the 
paralytic action of the drug throughout the experiment masks and 
covers up the convulsive influence. 





















DELI RIF A CIENTS. 


211 


It is very certain that in man atropine exerts this double influence; 
for the records of poisoning-cases are at once the records of convul¬ 
sions and of paralysis. It would seem that early profound paralysis 
occurs when a very large dose of the poison has been taken in its con¬ 
centrated alkaloidal condition, and consequently has been rapidly ab¬ 
sorbed and suddenly precipitated upon the nervous system. 

In the experiments of Botkin, made by tying the vessels of the 
frog’s legs, as described on page 208, the investigator found that al¬ 
though for a time ii'ritation of the foot of the perfectly paralyzed leg 
would cause spasms in the opposite limb whose nerve was protected, 
yet later in the poisoning, although irritation of the foot of the pro¬ 
tected leg caused movements in that leg, no irritation of the opposite 
poisoned foot was able to induce any response whatever on either side. 
From this he drew the inevitable conclusion that, while atropine 
paralyzes first the motor nerves, yet later it acts also on the afferent 
nerves. The very beautiful experiments of Dr. Fraser, already quoted, 
certainly show that the afferent nerves enjoy a comparative immunity 
from the influence of atropine in large doses. For when one leg of a 
frog was protected by tying the crural artery during the period of 
general paralysis, any irritation of the poisoned leg would produce 
immediate reflex convulsions in the unpoisoned extremity,—a demon¬ 
stration that while the functions of the efferent or motor nerves were 
suspended wherever the poison reached, the afferent nerves retained 
more or less of their activity. This of course confirms a portion of 
the experiments and conclusions of Botkin, and does not disprove that 
atropine acts to some extent upon the afferent nerves; for a very feeble 
impulse reaching the cord in its excited condition would cause reflex 
movements. Bezold and Bloebaum (loc. cit., p. 20) have investigated 
this subject by exposing the sciatic nerves of a strychnized frog, im¬ 
mersing them for a portion of their course, the one in a solution of 
atropine, the other in a solution of the phosphate of sodium, and then 
testing the effect of the application of stimuli in causing reflex move¬ 
ments. The result was not very satisfactory, so many sources of fallacy 
arising—sources not necessary here to point out—as to vitiate greatly 
the experiments. They certainly found, however, that the nerve-trunk 
preserved for some time its power of transmitting impulse even when 
immersed in a two-and-a-half-per-cent. solution of the alkaloid. Bezold 
and Bloebaum (p. 25) also repeated the experiments of Botkin, substan¬ 
tially confirming them, but showing that very large doses are necessary 
to affect seriously the conducting powers of the afferent nerves. 

The following experiments of Meuriot (loc. cit., p. 95) prove con¬ 
clusively that atropine does influence the afferent nerves. He found 
that if a frog be bound tightly around the body so as to interrupt the 
circulation, and then be poisoned by atropine in the front part of its 
body, at first irritations in any part give rise to general spasms, but 
after a time in order to get any movements of the hind legs it is neces- 


212 


GENERAL REMEDIES. 


sary to apply an irritant to them. Again, the hinder parts of a frog 
were so bound by ligatures as to cut off on the one side all communi¬ 
cation except by the nerves, and on the other to leave free the nerve 
and the vessels. A strong injection of atropine was then given, and 
when the moment came that irritation of the periphery of the leg 
whose circulation was free would no longer cause reflex spasms, the 
artery of this leg also was tied, so that both legs, the one atropinized, 
the other not, were now connected with the body of the frog only by 
their nerves. Strychnine was given hypodermically, and it was found 
that, while irritation of the atropinized leg had no effect, stimulation 
of the non-atropinized leg gave rise to general convulsions. The whole 
present evidence shows that atropine depresses the afferent nerves , but 
much more feebly than it does the efferent nerves. Miss Mary Putnam 
(JV. Y. Med. Rec., 1873) asserts that if the general tissue of the frog’s 
limb be tied, the vessels and nerves being left intact, so as to prevent 
diffusion of the poison through the cellular tissue, the sensitive nerves 
are alone affected by atropine. As no details of experiments are given, 
the matter rests simply upon the assertion of Miss Putnam. It is 
very difficult to imagine why a nerve should be affected differently by 
a poison when reaching it by different routes, and equally difficult to 
conceive how the poison should reach more effectively the motor than 
the sensitive nerves by diffusion. Further, it is also almost as unrea¬ 
sonable to believe that any perceptible diffusion through the cellular 
tissue should occur wffien the seat of injection is in a distant part of 
the body. Taking together the facts that Miss Putnam’s assertion is 
unsupported by detailed experiments, is exceedingly improbable, and is 
seemingly opposed to an enormous mass of experimentation by some 
of the most experienced and able investigators that have ever lived, it 
seems to me that it cannot be accepted. It is probable that atropine 
acts upon the peripheral filaments of the nerves more quickly than 
upon the main trunks; this is corroborated by Miss Putnam, who states 
that she has seen galvanization of a sciatic nerve cause indications of 
pain in an atropinized animal when the peripheral sensation was already 
lost. 

There can be no doubt that in the higher animals atropine acts upon 
the cerebrum as it does in man, producing the same peculiar delirious 
intoxication often ending in stupor. It is not necessary to discuss this 
matter further, except to remark that belladonna is not a hypnotic. 
The fact that the exhibition of a remedy is followed by sleep in disease 
is no proof that the remedy is in a proper sense a hypnotic. No one 
would give oyster soup such a cognomen, yet in certain exhausted 
wakeful states of the system such food may bring back sound sleep. 
If belladonna ever acts as a hypnotic, it is in this indirect way, by 
removing some cause of abnormal wakefulness. It can never be relied 
on, like opium, to induce sleep. 

Action on the Voluntary Muscles .—The voluntary muscles escape un- 


DEL1RIFA Cl ENTS. 


213 


scathed in atropine-poisoning. It is true that Lemattre has shown that 
the contractility of a striated muscle may be destroyed by soaking it 
in a very concentrated solution of the alkaloid; but long before any 
such action can take place in life the animal is killed; consequently 
after death from belladonna the contractility of the voluntary muscles 
is found unimpaired. 

Action on the Abdominal Canal. —On the non-striated muscles the 
action of the drug is pronounced, but its exact nature is uncertain. 
Meuriot states ( loc. cit ., p. 112) that if the belly of an animal poisoned 
by atropine be opened, the intestines will be found undergoing violent 
contractions, and that belladonna is a powerful excitant of the non- 
striated muscles. On the other hand, Bezold and Bloebaum affirm 
that they have experimented upon the intestines, bladder, uterus, and 
ureters, and that in all cases there is a state of marked sedation from 
atropine, and that, whether a small or a large dose be used (loc. cit., p. 
65), there are produced muscular quietness and relaxation in all these 
organs,—evidences of sedation not preceded by any stage of excite¬ 
ment, and always accompanied by lessening of the electro-muscular 
sensibility. They state, further, that by the use of sufficient doses abso¬ 
lute muscular paralysis of the organs above named is induced, so that 
the strongest faradic currents are unable to cause any motion. P. Keu- 
chel ( Das Atropin und der Hemmungsnerven , Inaug. Diss., Dorpat, 1868) 
has made a most elaborate series of experiments to determine the 
effect of atropine upon the inhibitory fibres of the splanchnic nerve. 
It has been shown by Pfliiger that galvanization of the peripheral 
ends of the divided splanchnics causes immediate arrest of the peri¬ 
staltic intestinal movements, and, although the subject has not been 
absolutely worked 'out, it is almost certain that some of the splanchnic 
fibres are the inhibitory nerves of the intestinal coats. Keuchel has 
found that even when doses of atropine so small as not to affect dis 
tinctly the motor nerves are given, galvanization of the splanchnics 
fails to influence the intestines, whose vermicular movements are still 
active, and therefore that atropine paralyzes the peripheral inhibitory 
intestinal apparatus precisely as it does that of the heart. There is, 
of course, a seeming disagreement between these researches and those 
of Meuriot and of Bezold and Bloebaum; and the apparent confusion 
is increased by the assertion of Dr. I. Ott (TVi Y. Aled. Journal, 1883, 
170), that minute doses of atropine prevent the production of peristal¬ 
sis by salt placed upon the intestine, while large doses exaggerate the 
action of the salt. It would appear from this that atropine first stimu¬ 
lates the intestinal inhibitory nervous system, then paralyzes it. Before 
the question can be settled, further researches are necessary, but it is 
possible that all these observers saw and reported correctly, the differ¬ 
ences being the result of varying doses. It appears certain that, in 
full doses, atropine paralyzes the smooth muscular fibres of the intes¬ 
tine, bladder, etc., and it may be that in any dose it depresses their 


214 


GENERAL REMEDIES. 


activity directly, but that, by paralyzing moi’e quickly the inhibitory 
apparatus, it sometimes places the intestinal muscular coat in such a 
position that it will respond more vigorously than normal to external 
stimuli, and also that very minute doses may cause quiet by producing 
inhibitory stimulation. This view is borne out by the fact that the 
smallest dose used by Keuchel was 0.075 gr., by Ott 0.015 gr., both 
observers experimenting on the rabbit. When Ott used 0.45 gr. he 
got the same result as did Iveuchel. 

Action on the Respiratory System. —It has already been stated that 
in man small doses of atropine do not affect the respiration, whereas 
large doses accelerate it. The same is true in animals; and the accel¬ 
eration takes place even when the vagi have been previously divided,— 
a proof that it is due to a direct stimulation of the respiratory centres 
in the medulla. (Bezold and Bloebaum, loc. cit., p. 59.) When very 
large fatal doses are administered, there is evidently also a paralysis of 
that portion of the peripheral pneumogastric nerve which is connected 
with the function of respiration; for if in an animal suffering only 
from a moderate dose the par vagum be cut, respiration is profoundly 
affected, but when the alkaloid has been more freely given, no marked 
influence is exerted upon the expiratory rhythm by section of the 
pneumogastrics. As death approaches in belladonna-poisoning, the 
blood, which has preserved its normal coloration, may become very 
dark, and the patient may at last die of asphyxia,—probably not 
entirely from failure of the centres themselves, but also, in part, from 
the loss of functional power in the respiratory nerves. 

Action on the Glandular System. —One of the earliest and most nota¬ 
ble effects of medicinal doses of atropine is dryness of the mouth, due 
to suppression of the secretions of the mucous and salivary glands. 
The action of the alkaloid upon the skin is similar. It can scarcely be 
doubted that this arrest of secretion is nervous; and the experiments 
of Keuchel indicate that it is due to an action upon the peripheral 
nerve-filaments. As was first discovered by Schiff, section of the 
chorda tympani is followed by arrest of secretion of the submaxillary 
gland, and galvanization of the peripheral end produces a greatly in¬ 
creased flow of saliva. In Keuchel’s experiments these phenomena 
occurred in the unpoisoned animal, but when atropine had been ex¬ 
hibited, galvanization of the peripheral chorda tympani was powerless 
to excite secretion,—proof that the peripheral end of the nerve was 
paralyzed. 

Elimination. —When atropine is exhibited medicinally it probably all 
escapes from the body through the kidney; and even after poisonous 
doses the amount eliminated through other channels must be almost 
infinitely small. 

Action on the Secretions. —After small doses of atropine the urine 
is increased,—sometimes, according to Harley, doubled. 1 am confi¬ 
dent, however, that this increase varies greatly, and is not always 


DELI RIF A CIENTS. 


215 


marked. After very large toxic doses the urine may be at first in¬ 
creased, but is usually lessened very early, and in the latter stages may 
be entirely suppressed * Meuriot states that the secretion of urino 
rises and falls in atropine-poisoning with the arterial pressure. The 
experiments of Harley upon men (Joe. cit ., p. 214) would appear to 
show that medicinal doses of atropine decidedly increase the solids of 
the urine, slightly the urea and uric acid, very markedly the phosphates 
and the sulphates. 

In regard to the secretions of the alimentary canal, the action of 
atropine is very uncertain. It has been a matter of traditional and 
clinical belief that they were increased, and Harley gives some experi¬ 
ments which he claims corroborate this; Meuriot, on the other hand, 
states that they are lessened. I cannot find, however, any experiments 
that seem to me decisive; and clinical evidence certainly indicates that 
the alimentary secretions, if atfected at all, are increased. 

Action on the Temperature .—In moderate doses atropine causes a pro¬ 
nounced rise in temperature, but in very large decidedly toxic amounts 
it lessens animal heat. Thus, in the dog, Meuriot has obtained an aug¬ 
mentation of from 1° to 3° C., and Dumeril, Demarquay, and Lecomtef 
of 4° C. In fatal poisoning of the same animal, these observers have 
noticed a fall respectively of 5^° and of 3°.f In man, Meuriot, in the 
use of medicinal doses, has observed the temperature to rise z° to 1^°, 
and Eulenburgf 1° to T 8 T °.| Harley has seen in man an elevation of 
1° F. Drs. I. Ott and C. Collmar ( Therap. Gaz., Aug. 1887) have found 
that the increase of the bodily temperature produced by atropine is in¬ 
dependent of the blood-pressure, occurring both when the pressure is 
elevated and when it is depressed. They also find that there is marked 
increase both of heat-production and of heat-dissipation, the produc¬ 
tion being, however, affected more distinctly than the dissipation. It 
follows from these experiments that the cause of the rise of tempera¬ 
ture is increased heat-production, which is the result, in all probability, 
of an influence upon the nerve-centres. Di’s. Ott and Collmar believe 
that this influence is a stimulation of the thermo-genetic centres in the 
spinal cord, and that the rise of temperature is paralleled by that which 
occurs in tetanus. The final fall of temperature in atropine-poisoning is 
probably caused by the vaso-motor paralysis. 

Summary .—From what has been already stated, it is evident that 
the actions of atropine in therapeutic and in toxic doses are in a sense 
quite different. 

In full medicinal doses it produces a sort of febrile state, with 
dryness of the mouth, increased rapidity and force of the circulation, 
quickened respiration, elevation of temperature, and secretion of febrile 


* See case of Dr. Gross ( loc. cit.), also of Dr. Morer (Ann. Soc. de Med. de Gand, 1873). 
f Quoted by Meuriot, p. 111. 

J These figures are probably all of them Centigrade, though it is not so stated by Meuriot. 




216 


GENERAL REMEDIES. 


urine. The rapidity of the heart’s action is due to paralysis of the 
peripheral inhibitory nerve and to stimulation of the accelerator nerves; 
the increased arterial pressure, to the increased cardiac action, together 
with the general contraction of the capillaries, the result of excitation 
of the vaso-motor centres. The spinal cord is not sensibly affected by 
these doses; the motor and probably to a much less degree the sensory 
peripheral nerves suffer lessening of functional activity, although the 
influence of therapeutic doses of atropine upon them must be very 
slight. If the dose be sufficiently large, the cerebrum is thrown into 
a condition of mild delirium, resembling that of fever. 

After decidedly toxic doses of atropine, the blood-pressure falls, 
from dilatation of the capillaries, owing to the paralysis of their mus¬ 
cular coats, and from direct laming of the heart-muscle. The tempera¬ 
ture also falls; the muscular system is relaxed, and sensation is impaired, 
from the paresis of the motor and sensory nerves respectively; yet 
convulsions may now occur from the over-activity of the reflex centres, 
the predominance of paralysis or of convulsions varying with the dose, 
accordingly as the depressing or the stimulating influence is the more 
powerful. Delirium precedes stupor, which in turn precedes death, 
from asphyxia, caused by depression of the respiratory centre and of 
the motor nerve-trunks, or very rarely from syncope, caused by failure 
of the cardiac muscle. 

Local Action .—It is evident that when belladonna is applied to a 
part it must act locally as a paralyzant, no doubt overpowering the 
capillary walls, the sensory and motor nerves, and even muscular and 
glandular cell-action; for, except in the case of the latter, experimental 
evidence has already been brought forward to prove that, locally and 
freely applied, belladonna is a sedative poison, and clinical evidence 
points very strongly to its exerting a similar influence upon gland-cells. 
A. Zeller ( Virchow's Archiv , lxvi. 384) has found that a one-per-cent, 
solution of atropine brought in contact with the blood, outside of the 
body, has a decided influence in arresting the movements of the cor¬ 
puscles. 

Action on the Eye .—Atropine placed in the eye, or given internally, 
dilates the pupils of all animals except birds. Accompanying this 
mydriasis are paralysis of accommodation and an alteration of intra¬ 
ocular pressure. In regard to the latter, the subject is so intricate that 
even the specialists differ in their views concerning it, and I must refer 
the reader to special treatises upon it. The latest research with which 
I am acquainted is that of Holtzke {Archiv fur Physiol., 1885, 564),* who 
states that the atropine plainly by its own action lessens the intra-ocular 
pressure, but that it subsequently increases it by the dilatation of the 
pupil which it causes. 


® See also Der intraoculare Druclc und die Innervations- Verhdltnisse der Iris. Von 
Professor Dr. Stellwag von Carion. Wien, 1868. 



DELI RIF A CIENTS. 


217 


Before discussing briefly the action of atropine upon the pupil, the 
fact that a recent American female writer has reasserted the old theory 
that the movements of the iris are due to erectile tissue, or, in other 
words, to its blood-vessels, seems to l’ender necessary a few words as to 
the real motile power of the part. In the first place, it is an indisputa¬ 
ble anatomical fact that the iris is largely composed of muscular fibres, 
and it is a simple common-sense deduction that the muscular fibres are 
there for the purpose of causing motion, especially since, in many 
animals, it can be readily demonstrated that while some of these fibres 
are circular, others are radiating, so that by position they become an¬ 
tagonistic. The paper of Dr. Arlt ( Archiv fur Ophthalmologie, 1869) 
seems to me decisive. In a very elaborate seines of experiments it 
was found that when the upper cervical ganglion was stimulated the 
pupil dilated long before any influence upon the vessels was detected, 
and that on cessation of the stimulation the pupil became natural long 
before the spasm of the vessels yielded; to my mind a proof that the 
ganglion has fibres other than vaso-motor,—fibres which control the 
muscular actions of the iris, and are more sensitive than the vaso-motor 
filaments; and, secondarily, a proof that the movements of the iris are 
not due to movements of the blood-vessels. Space cannot be afforded 
in the present work for a further discussion of this subject. The reader 
is respectfully referred for further information to books on the physiol¬ 
ogy of the eye, and especially to Engelhardt’s paper, Beitrdge zur Lehre 
von den Bewegungen der Iris ( Untersuch. aus dem physiolog. Laboratorium 
in Wurzburg, Theil ii.). 

In considering the action of belladonna upon the eye, it is necessary 
to view separately its influence when applied locally and when given 
internally; and I shall consider these influences in the order in which 
they here stand. 

It may be first asserted that the dilatation induced by the local ap¬ 
plication of belladonna or of its principles is a nervous phenomenon, and 
not due to a direct action of the drug upon the muscular fibres of the 
iris; for as all of these, both the radiating and the circular, are of the 
same nature (non-striated in mammals), their antagonism is simply due 
to position; and it seems inconceivable that mere position should affect 
the relations between a muscle and a drug. Moreover, decisive proof 
is afforded by the experiments of Bernstein and Dogiel, who found that 
while galvanic irritation of the oculo-motor nerve was unable to cause 
contraction of the pupil in the atropinized eye, yet when the electrodes 
were applied to the eyes in such a way as to affect directly the iris, 
contraction occurred,—phenomena explainable only by the theory that 
the nerve-endings were paralyzed, while the muscle was unaffected. Of 
the truth of this observation there can be no doubt, as it has been con¬ 
firmed by Dr. G-. Engelhardt ( Untersuch. aus dem physiolog. Laboratorium 
in Wurzburg, Theil ii. S. 321). 

The statement first made by Wharton Jones (.Med. Times and Gaz., 


218 


GENERAL REMEDIES. 


1857), that the reason atropine does not dilate the pupils of birds is that 
their irides have no radiating fibres, has been disproved by the beautiful 
anatomical researches of Alex. Ivanoff and Alex. Eollett ( Archiv fur 
Ophthalm ., vol. xv. p. 1), confirmed by Johannes Diegel ( Max Schulize's 
Archiv fur Microscop. Anat., Bd. vi. Heft i., 1870). Although Professor 
Donders ( Accommodation and Refraction , New Syd. Soc. ed., p. 584) says 
that the pupillary action of atropine “ is slight in birds, in whom it was 
formerly overlooked,” in my own experiments the most thorough appli¬ 
cation of very strong solutions to the eyes of pigeons has had no dis¬ 
tinct etfect. In previous editions of this book I ventured the surmise 
that the lack of action of atropine upon the irides of birds might be 
due to the muscle being of the striated type. According to the experi¬ 
ments of Szpilman and Luchsinger, this supposition is correct. In the 
oesophagus of the bird the muscle is non-striated, and atropine para¬ 
lyzes it; in the oesophagus of the rabbit the muscle is striated, and 
atropine has no action; in the cat a portion of the oesophagus has 
smooth muscular fibres, a part striated, and the former is paralyzed, 
the latter unaffected, by atropine (Arch. f. d. Ges. Physiol., xxvi. 460). 

The dilatation of the pupil by the local application of atropine* 
is certainly independent of any nerve-centres farther back than the 
ciliary ganglion. This is proved by the following facts. Claude Ber¬ 
nard ( Physiol. et Pathol, du Systeme nerveux , Paris, vol. ii. p. 212) and 
Lemattre (loc. cit .) both have fbund that atropine-mydriasis occurs in 
animals after section of the oculo-motor, and I have seen it in cases of 
complete oculo-motor paralysis in man. It also takes place after sec¬ 
tion of the trigeminus or of the cervical sympathetic, or of both of 
these nerves, as is shown by the testimony of numerous observers and 
by my own experiments. In man, I have seen it after paralysis of the 
sympathetic ( Phila. Med. Times , vol. i. p. 290). The dilatation of the 
pupil bv the local application of atropine is independent not only of 
the central nervous sj^stem, but also of the ciliary ganglion, and it is 
therefore due to an action exerted directly upon the nerve-endings in the 
iris. The experiments of Bernstein and Dogiel, confirmed by Engel- 
hardt, already quoted, are in themselves almost enough to establish the 
truth of this proposition. More direct evidence is not, however, want¬ 
ing. Thus, Vierordtf has found that atropine locally applied causes 
mydriasis after the removal of the ciliary ganglion. Professor I. Hoppe 
(Die Nervenwirkungen der Heilmittel, Leipsic, 1856, Heft ii. S. 179) has 
discovered, and Y. Yalentin (Versuch einer physiolog. Pathologie der Ner- 
ven, Leipsic, 1864, Abtheilung ii. S. 368) has confirmed the discovery, 
that in the eye of the frog removed from the body atropine will 


* Contraction of the pupil before dilatation noticed in dogs (Reese) and rabbits (Ross- 
bach and Frohlich) is probably caused reflexly by the irritant action of the atropine. 

f Unfortunately, the only notice I have seen of this capital experiment is in Hermann’s 
Grundriss der Phyexologie. No reference is given, and I have been unable to find the original 
paper. 



DELIRIFA Cl ENTS. 


219 


produce dilatation of the pupil. According to Borelli ( Edinb. Med. 
Journ., Nov. 1871), mydriasis is produced by the alkaloid when applied 
to the eye of a man just dead. Lastly, the presence of the alkaloid in 
the humors of the atropinized eye has been proved by numerous ob¬ 
servers, among whom may be mentioned Lemattre (loc. cit., p. 55) and 
Professor Donders (loc. cit., p. 588), who have found that the liquids 
removed from such an eye are capable of causing dilatation of the 
pupil of another eye. 

It having been demonstrated that the mydriasis of the atropinized 
eye is the result of an action upon the peripheral nerve-fibres, the ques¬ 
tion arises, Are the ends of the oculo-motor, the contractor of the pupil, 
paratyzed, or are the ends of the sympathetic, the dilator, stimulated, 
or is there a double influence, both of these actions occurring ? Both 
Donders (loc. cit., p. 589)* and Stellwag von Carion (loc. cit., p. 92) insist 
that the paralysis of accommodation is proof of paralysis of the oculo¬ 
motor nerve, and it seems to me they do so with truth. However this 
may be, there is abundant direct proof that the oculo-motor fibres are 
paralyzed, since the experiments of Grunhagen, which prove that gal¬ 
vanization of the exposed oculo-motor nerve does not affect the atro¬ 
pinized pupil, have been confirmed by Engelhardt (loc. cit., p. 321) and 
by Rossbach and Frohlich (Pliarmak. Untersuchungen, Wurzburg, i. 6). 

In artificial mydriasis there is, then, undoubtedly peripheral palsy 
of the oculo-motor. The question arises, Is there also stimulation of 
the dilating nerve? The evidence as to this is not so positive, but to my 
mind indicates very strongly that there is such an action. Clinical ex¬ 
perience certainly shows that the dilatation produced by a mydriatic is 
not merely a passive movement of relaxation, but is active, capable of 
tearing up inflammatory adhesions even when of some firmness. Again, 
the dilatation that occurs after the paralysis of the oculo-motor nerve 
in man and after its destruction in animals is not at all equal to that 
produced by atropine, and, indeed, can be largely increased by the 
action of the drug; further, in the eye separated entirely from the 
nerve-centres (see above) atropine still causes a wide dilatation; facts 
which necessitate the belief either that the alkaloid acts upon the 
sympathetic fibrillse, or that the peripheral fibres of a nerve are in 
themselves nerve-centres, acting upon the muscle of themselves even 
when separated from their centres. 

It has been urged against the view here taken that even the widest 
artificial mydriasis is increased by galvanization of the sympathetic. 
De Ruiter states the contrary; but, since Grunhagen, Hirsehmann, 
and Engelhardt separately affirm as the result of personal experiment 
the correctness of the asserted fact, it must be accepted. Granting 
its truth, I do not think it warrants the deduction, since it is con¬ 
ceivable that an agent may excite the peripheral filaments of a nerve 


* See also Yon Graefe, Deutsche Klinik, 3861. 




220 


GENERAL REMEDIES. 


greatly, and yet not to such a point that they shall be incapable of 
further excitation. 

In conclusion, the action of atropine applied to the eye may be 
summed up as follows: the mydriasis is the result of a direct influence 
upon the peripheral nerve-fibres, those of the oculo-motor being cer¬ 
tainly paralyzed, those of the sympathetic and its ally the trigeminus 
being probably excited. 

In regard to the constitutional action of atropine, it is evident that 
when the alkaloid is administered internally there are only four possi¬ 
ble ways in which it can cause mydriasis, and that these are as follows: 
1. By acting alone on the sympathetic centres, as a stimulant. 2. By 
acting alone on the oculo-motor centres, as a paralyzant. 3. By com¬ 
bining these actions. 4. By being carried to the eye, and acting as 
though locally applied. 

Authors are greatly at variance in their conclusions: thus, Ilarley 
(The Old Vegetable Neurotics ) and Hayden ( Dublin Quart. Journ., 
August, 1863) may be cited as in favor of the first view, and Budge 
(Ueber die Bewegung der Iris, 1855), Braun ( Archiv fur Ophthalm ., Bd. 
v. Abth. ii.), and Hirschmann ( Reichert's Archiv , 1863) as favoring the 
second. Neither the first nor the second view is, however, tenable : 
the first, because of a fact which has been asserted by authorities and 
which I have experimentally corroborated, namely, that atropine given 
hypodermically causes dilatation of the pupil after section both of the 
trigeminus and of the sympathetic in the neck ; the second, for the 
reason that after section of the oculo-motor in animals, or after com¬ 
plete paralysis of the oculo-motor in man, the mydriasis is much less 
than that of atropine-poisoning. 

In regard to the third view, I have noticed that the dilatation of 
the pupil under the constitutional action of the alkaloid after section 
of the cervical sympathetic is still greater than that which is normally 
produced by oculo-motor paralysis. At my solicitation, Dr. T. Gr. Mor¬ 
ton, of this city, cut down to the optic nerve in a rabbit and divided 
all the structures about it. The pupil contracted very much at the 
time; the cornea was not sensitive, but recovered its sensitiveness in 
part after some days. Atropine given hypodermically dilated the eye 
very markedly, but not nearly to the extent of the other eye. If in 
this experiment all the ciliary nerves were really cut, the proof is con¬ 
clusive that the mydriasis is not of centric origin; the reason that the 
pupil did not dilate so freely as the other being the strong contracting 
influence it was under, and the great reduction in the amount of blood 
— i.e., the amount of atropine—entering the eye, owing to the division 
of the blood-vessels. 

An experiment of Lemattre, if it be accurate, is also conclusive in 
proving that the action of the mydriatics upon the pupil, even when 
administered internally, is a peripheral one. He succeeded in pro¬ 
ducing mydriasis in normal eyes by placing in them aqueous humors 


DELIRIFA Cl ENTS. 


221 


taken from dogs poisoned with atropine, and even from a foetus whose 
dam had been killed by the alkaloid. Donders, however (loc. cit., p. 589), 
failed to get the dilatation; and two or three experiments have yielded 
me the same negative result. It requires no elaborate argument to 
prove that in this case a negative result does not overpower a previ¬ 
ous positive one : still, the experiments of Lemattre need confirmation. 
In the Pennsylvania Hospital, under the care of Dr. Morton, not long 
since, I saw a man who had been wounded by a railroad-accident in 
such a way that the whole of the temporal bone anterior to the petrous 
portion was thrust into the side of the head: there was complete 
paralysis of the facial, of the trigeminus, and of the oculo-motor, as 
could be readily demonstrated upon the man, who lived some months, 
finally dying suddenly of abscess of the brain. The carotid canal was 
so pressed upon that the sympathetic, which passed upwards through 
it to the eye, must have also been paralyzed. The eye was, as proved 
by the autopsy, separated from all connection with the nerve-centres, 
and yet when atropine was given hypodermically the pupil dilated. 
The proof seemed complete that the mydriasis was owing to a periph¬ 
eral action. 

Our knowledge of the action of atropine upon the pupil may be 
summed up as follows. Atropine applied locally causes mydriasis by 
paralyzing the peripheral ends of the oculo-motor nerve, and probably 
by stimulating the peripheral ends of the sympathetic. Atropine given 
internally causes mydriasis, not by influencing the nerve-centres, but 
by being carried in the blood to the eye itself and there acting precisely 
as when applied locally. 

Therapeutics. —The results of clinical experience are in strict accord 
with what is known of the physiological action of belladonna. The 
chief indication for its use is to relax spasm. In the case of voluntary 
muscles its powers are comparatively feeble, except when it is thrown 
directly into the muscle affected. In this manner Dr. S. Weir Mitchell 
(.Injuries of Nerves, Philadelphia, 1872, p. 258) has obtained very marked 
relief in the fearful spasms following nerve-wounds, and Dr. J. M. Da 
Costa in rheumatic spasm ( Pennsylvania Hosp. Rep., 1868). The benefit 
derived is evidently due to the depressing etfect of the drug upon the 
terminal nerve-filaments, with which it comes in direct contact, and 
to a certain extent also upon the muscle itself. When given by the 
mouth, so small an amount of the remedy reaches the diseased part as 
scarcely to affect it, and very little or no relief follows. As has been pre¬ 
viously shown, the non-striated muscles are more affected by belladonna 
than are the striated, and clinically the drug is found to be even more 
efficacious in spasm of the involuntary than of the voluntary muscles : 
in such cases it is often of value used internally. It may be thus ad¬ 
ministered in lead colic, —in simple spasmodic colic ,—in spasmodic dys- 
menorrhoea ,—in spasmodic constriction of the bowels with obstinate con¬ 
stipation, —in laryngismus stridulus, —in nervous cough, —in asthma, —in 


222 


GENERAL REMEDIES. 


hiccough , — in whooping-cough , — in which, as originally advised by Bre- 
tonneau, it has been largely used and is one of the best known reme¬ 
dies ; also, even in the spasms accompanying the passage of renal and 
biliary calculi , where of course it often fails. Wherever it is possible, 
however, it should be used locally in spasm of the involuntary as well 
as of the voluntary muscles. Thus, in spasm of the urethra , the oint¬ 
ment should be rubbed in along the canal; in rigid os uteri , the extract 
should be applied directly to the os; in asthma , belladonna should be 
inhaled, by means either of the cigarette or of the atomization of a 
decoction of the leaves; in spasm of the sphincter ani from fissure or 
other cause, it should be applied directly to the part by poultice or 
ointment. Under the present indication may be considered the use of 
the remedy in constipation. In doses of one-quarter to one-half grain 
of the extract, belladonna is of great service as an addition to laxative 
pills. 

It is, no doubt, by relaxing spasm, or rather by lessening irritability, 
that belladonna acts in that form of incontinence of urine which is seen 
generally in children. It has been taught that this affection is due to 
a relaxation of the sphincter, but often the real cause is an irritability 
of the bladder, so that spasmodic contraction occurs under the stimulus 
of a small portion of urine. Toxic doses of belladonna cause a paralytic 
retention of urine by the local action of the atropine in the urine upon 
the bladder. It is needless to point out more in detail how the indica¬ 
tions in incontinence are met. In these cases the drug must be given 
in as large doses as the system will bear, and the impression should be 
maintained for weeks. Usually the dose has to be steadily increased. 

To relieve Pain. —Physiologically viewed, atropine should be of little 
value for this purpose; and I think clinical evidence bears this out. 
Dr. Mitchell has had probably the best opportunities ever afforded for 
testing this, and he says decidedly that it is of little use in severe suf¬ 
fering. My own experience is to the same effect. There is, however, 
considerable evidence of its value in neuralgia , but it is chiefly as to its 
efficiency when injected immediately in the neighborhood of a painful 
nerve, or applied as inunction over its course when superficial. In 
large quantity, belladonna certainly affects the afferent nerves, and, 
used as above, may readily relieve pain. It is very probable also that 
at times it cures neuralgia by modifying the circulation in the affected 
part. Though these things be so, yet belladonna is almost immeasurably 
below opium as an analgesic. In some forms of neuralgia with spasm 
it is of service by a double action. 

To impress the Heart and Blood-Vessels. —Under the idea of its con¬ 
tracting the blood-vessels, belladonna has been highly commended by 
Dr. Harley (loc. cit.) in pneumonia , acute nephritis , and various other 
acute diseases. I have had no experience with it in these affections, 
but the published accounts do not seem to me to indicate that it is 
of equal value with other remedies or combinations of remedies. In 


DELIR IF A Cl ENTS. 


223 


chronic albuminous nephritis I have tried it, as recommended by .Dr. 
Harley (loc. cit.), but have failed to derive any advantage from it. In 
ordinary sore throat it does good by acting upon the blood-vessels and 
by relaxing the pharyngeal muscles. It may possibly be of use, given 
before the administration of chloroform, to prevent cardiac inhibitory 
arrest. (See Brit. Med. Journ., 1880, ii. 620.) 

As a stimulant to the circulation, belladonna has probably not 
been employed as much as it ought. Dr. Graves, however, commends 
it especially when the pupil is contracted in typhus fever, and it has 
been used with asserted advantage in erysipelas, scarlet fever, etc. In 
cases of sudden collapse occurring in acute disease and marked by 
falling of the temperature below normal, with great loss of the arte¬ 
rial tension and free sweating, atropine is of the greatest value. Such 
collapse is not infrequent in young children in the advanced stages of 
pneumonia, pleurisy, or other jmlmonic disease, and is also prone to 
happen in puerperal mania and similar maniacal states occurring in 
exhausted patients. It is similar in its character to that which is pro¬ 
duced by perforations of the stomach or intestine or as the result of 
surgical or accidental traumatisms. It is a condition of shock in which 
the loss of temperature is chiefly the result of vaso-motor paralysis. 
In surgical cases also it is probable that excessive pneumogastric in¬ 
hibition is present. Proper treatment of this condition consists chiefly 
in the free use of external heat, the hypodermic injection of atropine 
and of the tincture of digitalis, and the internal administration of 
alcoholic stimulants: of all these drugs atropine is probably the most 
valuable. 

To arrest Secretion. —Arresting secretion of the salivary glands by 
paralyzing the extreme branches of the chorda tympani has already 
been shown to be a physiological action of belladonna, and it follows 
from this that the drug should be useful in ptyalism. I have tried it in 
several cases of mercurial salivation, and found that it arrests almost at 
once the discharge of saliva, and seemingly facilitates greatly the return 
to health. In colliquative sweats it was originally recommended by Pro¬ 
fessor Da Costa ( Phila. Med. Times, Feb. 15, 1871), and I have found 
it of very great service. A full dose of belladonna extract, or one- 
sixtieth to one-eightieth of a grain of atropine used hypodermically, at 
bedtime, will very frequently prevent the usual night-sweat. In colliqua¬ 
tive diarrhoea it has been recommended by M. Delpage, and very probably 
will be found of service. 

Inunctions of the breast with belladonna ointment are habitually 
employed for the purpose of arresting the secretion of milk, and in the 
experiments of Hammerbacher upon a goat atropine given internally 
lessened the secretion, especially of the watery portions of the milk 
( Arch, f. Gesammt. Physiol., xxxiii. 228). 

Employment in Poisoning .—It is stated that as far back as 1570 it 
was asserted that opium and belladonna are, in their influence upon 


224 


GENERAL REMEDIES. 


the system, antagonistic. In the early part of the present century 
their employment as counter-poisons was again brought prominently 
before the profession; but, although a few scattered earlier records of 
their use as such exist in medical literature, it was not until the paper 
of Dr. Wm. F. Norris appeared ( Amer. Journ. Med. Sci., Oct. 1862) 
that general attention was attracted to the subject. Since this publi¬ 
cation, very many cases of the use of the one medicine in poisoning 
by the other have been published. The opposite actions of bella¬ 
donna and of opium upon the pupils no doubt first suggested the idea 
of their antagonism ; but in the light of recent experiments these 
apparently opposite effects upon the eye cannot be considered as proving 
any antagonism between the drugs, since the dilatation is due to a 
peripheric and the contraction to a centric influence. In an investi¬ 
gation by Dr. J. Hughes Bennett (Brit. Med. Journ ., 1874, ii. 547), 
twenty-one rabbits received what previous experimentation had shown 
to be a fatal dose of meconate of morphine (10 grains), and afterwards 
sulphate of atropine; six recovered; and of these six, four some weeks 
afterwards were killed by a dose of 10 grains of the morphine salt. 
Eleven rabbits received a dose of sulphate of atropine (If to 2 grains), 
and afterwards 10 grains of the meconate of morphine; seven recov¬ 
ered, and some weeks afterwards the meconate of morphine (10 grains) 
being given, four of them succumbed to it. Again, two dogs received 
the fatal dose of meconate of morphine (21 grains), and afterwards sul¬ 
phate of atropine, and recovered, only to die some days afterwards from 
the effects of a second two-and-a-quarter-grain dose of the opium salt. 
These experiments certainly warrant the conclusion of Dr. Bennett that 
atropine is physiologically antagonistic to morphine within a limited area, 
and that it exerts in dogs and rabbits a beneficial influence in opium¬ 
poisoning. Dr. Corona (London Med. Record , 1877, p. 341) and Pro¬ 
fessor Btirz ( Deutsch. Med. Wochenschr., Jan. 1887) have experimentally 
reached conclusions very similar to those of Bennett. What I affirmed 
in the first edition of this work, namely, that our present knowledge of 
the physiological action of the two drugs renders a complete antagonism 
very improbable, is still as true as it is obvious. 

When the subject in hand is looked at from its clinical aspect, the 
conclusion of Dr. Bennett is confirmed. To tabulate and discuss the 
reported cases of opium- or belladonna-poisoning in which the counter¬ 
narcotic has been used would require very many pages, and I therefore 
shall only state my opinion that these records establish the therapeutic 
value of atropine in opium-poisoning, but this does not indicate, much 
less prove, complete antagonism between the two drugs. No one wmuld 
question the value of alcohol in certain stages or conditions of opium¬ 
poisoning, and yet no one would assert that opium and alcohol are in any 
sense antagonistic. In opium-poisoning, death occurs chiefly through 
failure of the respiration. Atropine is the most powerful and prompt 
of the respiratory stimulants, and as such is invaluable in the treat- 


DELIRIFA Cl ENTS. 


225 


merit of opium-poisoning. In protracted opium-narcosis the cardiac 
and vaso-motor actions of atropine are of service; but it should never 
be forgotten that the main influence for good is upon the respiratory 
centres.* The first improvement from atropine in these cases is usu¬ 
ally increased frequency of respiration; and as the breathing becomes 
less embarrassed the other symptoms ameliorate, largely because of the 
increased aeration of the blood. 

The double nature of profound opium-narcosis must not be lost sight 
of: the blood is saturated with carbonic acid almost to the dead-line, and 
much of the unconsciousness, much of the failing circulation, much even 
of the embarrassed respiration, is due to the presence of the gas. As 
soon as the system is in a measure relieved of this load, it begins to re¬ 
bound ; emetics act, consciousness returns to some extent, the circulation 
frees itself, and the road leading towards health is entered upon. It is 
a matter of the gravest practical importance to decide when, how, and 
in what quantities the mydriatic should be employed. The exhibition 
of belladonna should, I think, commence as soon as there is decided 
failure of the respiration. The stomach is so paralyzed in the narcosis 
from it that it is uncertain how fast absorption will take place from 
it; and the drug should always be given hypodermically, in the form 
of the alkaloid if possible. The first injection of atropine should be 
of such size that it could not possibly do harm; and one-fortieth of a 
grain is in most instances a fair commencing dose. Very generally 
several repetitions of this are necessary, and the delicate practical point 
is to decide how often these repetitions shall be indulged in. 

I think that frequently too much atropine is given, and believe that 
often a great deal of firmness is required in these cases not to use it 
too freely, especially since reliance is generally placed upon the pupils 
as a guide. They are in fact a very unsafe guide, as is apparent 
when it is remembered that while opium contracts them by influencing 
the nerve-centres, atropine dilates them by acting on the peripheral 
nerves. It must not be forgotten that in doses of sufficient magnitude 
atropine paralyzes the nerve-trunks, and may thus increase the danger. 
A cardinal principle should, therefore, be to give no more of the mydri¬ 
atic than is absolutely necessary. One-fortieth or one-sixtieth of a grain 
maybe injected every fifteen, twenty, or thirty minutes, as the urgency 
of the symptoms may demand. The judgment should be formed from 
a bird’s-eye view of the whole case, fresh atropine not being given so 
long as the respiration and other symptoms are undergoing ameliora¬ 
tion, but the dose being renewed so soon as any tendency to a relapse 
is manifested. Thus, if under the influence of atropine in a case the 
respirations had risen from four to eight per minute, I would not use 


* In the experiments of Heubach and Auerbach it was found that atropine produced very 
decided effects upon the circulation- and respiration-curves of dogs poisoned with opium. 
See Berlin. Klin. Wochenschr., 1878, 767. 


15 



226 


GENERAL REMEDIES. 


the counter-poison again until there was manifested a tendency for the 
respirations to grow less frequent, or unless for a long period there had 
been no improvement. 

Whenever there is failure of respiration in other poisonings than 
that of opium, atropine is useful. It has been especially commended as 
an antidote io poisonous fungi.* 

As a Local Sedative. —Locally and freely applied, belladonna is a 
sedative, and, I believe, to glandular as well as to muscular and ner¬ 
vous tissues. In this way it is often very useful in various local inflam¬ 
mations. In the form of a plaster it frequently appears to do good in 
palpitation of the heart. Its use locally in spasms and in neuralgia has 
been sufficiently dwelt on. In mastitis, or when it is desired to dry up 
the secretion of milk, its local application to the breast is often very 
efficacious. Whenever belladonna is used locally, in order to get its 
good effects it must be employed freely. At the same time, it should 
be remembered that a number of cases of poisoning by its external 
application have been reported ( Med. Times and Gazette, Nov. 1856; 
also London Pharm. Journ., 1871). In children it must be used with 
caution; in adults, with a reasonable amount of care, its external use 
is safe, provided directions be given to have it washed off so soon as 
any affection of the sight or dryness of the throat is induced. 

Having myself no practical knowledge of diseases of the eye, Hr. 
Wm. F. Norris, Clinical Professor of Diseases of the Eye in the Univer¬ 
sity of Pennsylvania, at my request has prepared the following section : 

The Use of Atropine in Diseases of the Eye. —Pure atropine, from 
its slight solubility in water, is only applicable where we desire a mod¬ 
erate effect; the sulphate, however, can be dissolved in water in any 
desired proportion, and, therefore, is generally employed. When a 
four-grain solution of this salt is dropped into the conjunctival sac of 
a healthy and emmetropic eye, we find that in about fifteen minutes 
the pupil commences to dilate, and that this dilatation rapidly in¬ 
creases, till in from twenty-five to thirty-five minutes it has attained 
its maximum. The power of accommodation, and consequent ability 
to read fine print, does not show any marked decrease till twenty-five 
minutes have elapsed, when the near point commences rapidly to re¬ 
cede from the eye, until in an hour and a half to an hour and forty 
minutes the power of accommodation is completely annulled, and only 
objects over twenty feet distant from the eye, or those presenting 
practically parallel rays, can be distinctly seen. On the second day 
after the application the power of accommodation begins to return, 
and increases rapidly up to the sixth day, but is usually not fully 
regained till from ten to fourteen days; the pupil remains with but 


* Consult The Doctor, 1874; Brit. Med. Journ., ii. 1874; Arch. Physiol. Normale, 1877, 
p. 831. 



DELIR1FA Cl ENTS. 


227 


little change till the third day, when it rapidly contracts, but has not 
fully regained its normal state till eleven or twelve days have elapsed.* 
The mydriatic action of the drug is far more marked from a moder¬ 
ately strong solution applied to the conjunctiva than from its internal 
use, even when it has been pushed to the production of symptoms of 
poisoning. Thus applied, it acts on the intraocular nerves and ganglia; 
and it has been proved by Graefe and Donders that when the aqueous 
humor of an animal is drawn off and collected after its application, it 
contains a sufficient amount of the drug to cause dilatation of the eye 
of another animal when applied to it. These experiments have been 
abundantly confirmed by later observers, and the rapidity of its action 
appears to depend on the thickness of the cornea and the age of the 
subject selected for the experiment. It will be apparent from the fore¬ 
going statements that the use of a strong solution of atropine is not 
to be undertaken without due consideration, inasmuch as it is likely to 
debar the patient from any satisfactory use of the eyes for a period of 
from eight to twelve days. It is, however, invaluable, from its annihila¬ 
tion of the accommodation, where we wish to determine with accuracy 
the refraction of the eye, and is daily used for this purpose in cases 
of hypermetropia where the patients find it impossible to relax their 
accommodation, in astigmatism where it is necessary to determine the 
exact difference between the two principal meridians of the cornea, 
and in the rare cases of myopia associated with spasm of the ciliary 
muscle. To obtain this complete paralysis of the accommodation, a 
few drops of a four-grain solution should be dropped in the eye, and 
this repeated after an interval of five minutes. The patient will be 
ready for examination one and a half hours subsequently. In the vast 
majority of cases it is entirely unnecessary to dilate the pupil to obtain 
a satisfactory view of the fundus with the ophthalmoscope; but where 
this becomes necessary we can often use with advantage a solution of 
one-twentieth grain in an ounce of water; a drop or two of this will 
dilate the pupil, without, however, rendering it absolutely immovable, 
and with scarcely any interference with the accommodation; on the 
next day the pupil is much smaller, and on the third day no trace 
of its action remains. In cases of suspected cataract the pupil should 
always be dilated ; otherwise we may readily fail to discover the lesion, 
which frequently first manifests itself in a few faint striae shooting out 
from the periphery of the lens. Moreover, it affords us a valuable 
prognostic point as to the probable success of any operation where the 
cataract is ripe; for where the iris fails to dilate ad maximum , we may 
be sure that it is more prone to take on inflammatory action, and 
more liable to be pressed on by any cortical matter which may remain 
behind in the eye. Daily experience shows that after the evacuation 


* For a more detailed discussion of this subject, see Donclers’s Anomalies of Refraction 
and Accommodation, p. 584, New Sydenham Society, 1S64. 



228 


GENERAL REMEDIES. 


of the aqueous humor in the operation for cataract, the iris will con¬ 
tract in spite of any previous use of atropine; but as soon as by the 
closing of the wound the humor reaccumulates and the anterior cham- 
her is re-established, the atropine resumes its sway. It is most useful 
in all inflammations of the cornea. In phlyctenular keratitis, by its 
local anaesthetic action on the branches of the trigeminus, it dimin¬ 
ishes the photophobia and blepharospasm, and seems to mitigate the 
intensity of the inflammation by its influence in contracting the ciliary 
vessels, thus diminishing the supply of nutritive material carried to 
the cornea. Where an ulcer has perforated the central region of the 
cornea, and a prolapse of the iris has ensued, the energetic use of 
atropine often enables the radiating fibres of the iris to detach it from 
the cornea as soon as the opening has been plugged by lymph, and the 
anterior chamber restored, thus preventing the formation of anterior 
synechise. Mackenzie long ago called attention to the “ healing and 
anodyne” effect of atropine in ulcers of the cornea occurring in the 
ophthalmia of new-born children,—a fact since universally recognized, 
and which holds good equally in the ulcers resulting from other forms 
of purulent conjunctivitis. It is held by many writers that part at 
least of this beneficial action is to be ascribed to its diminution of 
intraocular tension.* In cases of iritis a strong solution of atropine 
should at the outset be applied repeatedly at short intervals until we 
have obtained a full dilatation of the pupil, and subsequently suffi¬ 
ciently often to maintain the iris in this condition. We thus place 
the inflamed tissue at rest, diminish its blood-supply, and prevent the 
formation of posterior sjmechife, which constitute so frequent a cause 
of the recurrence of this disease by their mechanically-irritating effect, 
—putting a strain on the iris in its every motion, and hindering that 
variation in the diameter of the pupil which normally takes place with 
every change of convergence and with every variation of the intensity 
of light. Moreover, extensive synechiae where the iris is plastered 
down to the anterior capsule by large patches of lymph tend to pro¬ 
duce cataract, by interfering with the nutrition of the lens. Where 
the synechise are narrow and tongue-shaped, they may often be torn 
through by its action, even after the lapse of years. 


* That atropine diminishes intraocular pressure has been asserted by Graefe, Coccius, and 
many other good authorities; and a reference to any manual of diseases of the eye will show 
that it is an accepted doctrine with most clinical observers of the present day. Other weighty 
authorities, such as Donders and Stellwag, doubt its ability to produce any such effect. Cer¬ 
tainly it fails to reduce intraocular pressure in cases of glaucoma. Numerous attempts to 
decide the question by physiological experiment have been made by Hensen and Volckers, 
Wegner, Adamiuk, Griinhagen, Dor, etc. The results vary, however, considerably among 
themselves. Those with the manometer are open to the objection that the cutting open of the 
eyeball for its introduction quite changes the conditions of intraocular pressure and circula¬ 
tion, and that very slight movement of the instrument or eyeball invalidates the results; while 
those with the tenometer are also unsatisfactory, inasmuch as we have yet failed to obtain any 
reliable instrument for measuring intraocular tension. 



DELI RIF A Cl ENTS. 


229 


Atropine acts more powerfully in iritis after the abstraction of 
blood,* and occasionally, where there is much exudation, fails to pro¬ 
duce its etfect till after the constitutional effect of mercury has been 
obtained. In some individuals the instillation of a strong solution of 
atropine, by its rapid passage through the tear-passages into the nose 
and throat, produces symptoms of slight belladonna-poisoning,—viz., 
flushed face, rapid pulse, dryness of the throat, slight dysphagia; but 
this may usually be diminished or prevented by gargling the throat 
with water, by compressing the canaliculi, or by everting the lower 
punctum lachrymarum. In some individuals it produces a curiously- 
irritant action on the conjunctiva, known as atropine conjunctivitis; 
this is sometimes quite severe, calling forth almost erysipelatous symp¬ 
toms, at other times bringing out a crop of granulations. This is owing 
to idiosyncrasy, and will then happen with perfectly neutral solutions. 
It should in such cases be discontinued, and the conjunctivitis which it 
has called forth combated by weak solutions of alum and sulphate of 
zinc or other mild astringent. We find, too, in some cases of iritis, 
especially those occurring in rheumatic patients with posterior synechise 
due to repeated previous attacks, that not only do we fail to dilate the 
pupil, but that atropia acts as an irritant to the eye. We are then 
obliged to give up its use, and resort to the application of dry warmth 
and appropi'iate constitutional remedies. Atropine will occasionalljq in 
cases of chronic glaucoma, precipitate an acute attack, and is, therefore, 
to be used with due consideration in this disease, f 

A great deal has been written about the value of belladonna as a 
prophylactic in scarlatina , and authorities differ very much. For a 
discussion of the subject I must refer the reader to the treatises of 
Dr. Geo. B. Wood, Dr. Stille, Dr. Waring, etc. I have never had a 
decisive opportunity of testing the matter, but have no faith in the 
efficacy of the remedy. It ought to be tried further, however. The 
plan practised has been to dissolve two grains of the extract in a fluid- 
ounce of water, and give two drops daily to a child a year old, adding 
one drop for every year in older children up to twelve years. 

Toxicology.— Sufficient has already been said about the general 
symptoms of belladonna-poisoning. Those which are characteristic are 
the dryness of the throat, the increased frequency of breathing, the 
dilated pupils, the red efflorescence on the skin, the rapid pulse, the 
active talkative delirium, sometimes convulsions, all ending in abolition 
of function, as shown by stupor, rapid feeble pulse, cold extremities, 
and paralysis. If the urine of a patient suffering from belladonna¬ 
poisoning be dropped into the eye of the cat or rabbit, it will dilate 


* Mackenzie, Diseases of the Eye, p. 537, London, 1854. Graefe, Archie fur Ophthal¬ 
mologic, vol. ii. part 2, p. 209 (note). 

f Graefe, Archie fur Ophthalmologie, vol. xiv. part 2, p. 117. II. Derby, Trans. Amer. 
Ophthal. Soc., p. 35, 1868. Wells, Diseases of the Eye, p. 517 (2d Amer. ed.). 



230 


GENERAL REMEDIES. 


the pupil; and the diagnostician may avail himself of this test in any 
doubtful case. Dr. Morel ( Annales de la Soc. de Med. de Gand, 1873) 
calls attention to a sort of laryngitis produced by poisonous doses of 
belladonna, and characterized by pain in the larynx, roughness of voice, 
and the expectoration of minute, pearly, tough pellets. It was present 
in the advanced stages of two cases of poisoning under his care. 

The minimum fatal doses of the preparations of belladonna are 
scarcely known. An enema representing eighty grains of the root has 
produced death in five hours ( Casper's Wochenschrift , Feb. 1845); but, 
on the other hand, recovery has occurred after the ingestion of three 
drachms of the extract (Taylor’s Medical Jurisprudence , London, 1873, 
p. 432). A tenth, or even a twentieth, of a grain of atropine will often 
produce alarming symptoms; yet Dr. Chambers reports ( Lancet , 1864) 
recovery in a child four years old who had taken about two teaspoonfuls 
of a solution containing a grain of the alkaloid in half an ounce. 

After death from belladonna, no characteristic lesions are to be found. 

In the treatment of belladonna-poisoning, the first- indication is to 
prevent the absorption of any more of the poison. For this purpose 
emetics or the stomach-pump should be used. The same difficulties are 
to be met and the same measures adopted as in opium-narcosis: it is 
well to exhibit tannic acid freely, because it forms with the alkaloids 
salts which are soluble with difficulty. After the stomach has been 
evacuated, the various symptoms must be met as they arise. The exact 
value of opium in belladonna-poisoning has not, I think, been deter¬ 
mined, and its use should only be tentative, although good is to be 
expected from its judicious employment. In poisoning by a mydriatic, 
in order to keep up the respiration and the circulation during the stage 
of failure of function the same measures should be employed as in 
opium-poisoning. External stimulation by heat and by mustard, flagel¬ 
lations, etc., artificial respiration, and especially the use of the alternate 
cold and hot douche, should all be practised as necessary. Physostigma 
and jaborandi appear to be somewhat antagonistic to atropine within 
certain limits, and jaborandi has been used in atropine-poisoning ( Lancet , 
1876, i. 346). As this subject can best be elucidated after the dis¬ 
cussion of the action of the respective drugs, the reader is referred for 
further information to the articles upon Calabar bean and jaborandi. 
After toxic doses of belladonna, there is very generally complete reten¬ 
tion of urine; and as this secretion contains the greater part of the 
ingested poison, and as reabsorption in the bladder is at least conceiva¬ 
ble, the catheter should be used early. 

Administration. —Belladonna is never used internally in substance. 
All the preparations of the U. S. Pharmacopoeia except two (designated 
below) are made from the leaves. They are the tincture ( Tinctura Bel¬ 
ladonnas —1 to 6.66, U.S.), dose, ten to thirty drops ; the alcoholic extract 
(Extraction Belladonna} Alcoholicum), dose, one-eighth to one-half a 
grain; the fluid extract of the root (Extractum Belladonnas Fluidum ), 


DELIRIFA CJENTS. 


231 


dose, one to two minims; the plaster (Emplastrum Belladonnce *) repre¬ 
sents its weight of root; the ointment ( Unguentum Belladonnce) contains 
one-tenth of extract. The abstract (Abstractum Belladonnce ) represents 
twice its weight of root, dose, one grain. The sulphate of atropine 
(Atropince Sulphas) is most commonly used, on account of its solubility 
in water. One-sixtieth of a grain of atropine or its salt, given hypoder¬ 
mically, will generally produce slight dryness of the throat or other 
indications of its constitutional action. Where rapidity of action is 
required, this is the best method of administering belladonna. 

Hydrobromate op Homatropinf,.— Homatropine is an alkaloid arti¬ 
ficially produced from atropine, the hydrobromate of which is preferred 
for practical use on account of its being stable and not hygroscopic. It 
is said to produce, when taken internally, symptoms similar to those 
caused by atropine, except that it slows the pulse. This retardation 
has been proved by Tweedy and Einger, Beyer, and De Schweinitz and 
Hare (Med. News, 1887, li. 731) to be at least in part the result of 
a direct action of the drug upon the heart-muscle or its contained gan¬ 
glia, since in the frog and in the terrapin the application of homatro¬ 
pine hydrobromate to the exposed heart in situ reduces very greatly 
the number of the beats. In the dog injection of the alkaloid into 
the jugular vein is followed by a fall of as much as thirty or forty 
beats per minute, which Drs. De Schweinitz and Hare believe to be in 
part the result of stimulation of the vagi nerves, because section of tho 
vagi causes a marked increase in the pulse-rate, “ although not such a 
rise as would appear if the inhibitory apparatus was intact.” This in¬ 
crease of pulse-rate does not, however, to my mind prove that the drug 
stimulates the vagi, because if the primary slowing of the pulse were 
the result purely of an action upon the heart-muscle, unless that muscle 
were completely paralyzed, it would still feel to some extent the re¬ 
moval of the normal inhibition, and respond to section of the vagi by 
an increase in the rate of its contraction. De Schweinitz and Hare 
found that the fall of the pulse-rate was accompanied by a marked fall 
of the arterial pressure: as the production of asphyxia was followed 
at this time by a pronounced rise in the arterial pressure, it wmuld 
appear that the fall of pressure is not the result of a vaso-motor par¬ 
alysis, but of the cardiac influence of the drug. 

It has been shown by the experiments of Drs. Tweedy and Einger, 
confirmed by Drs. De Schweinitz and Hare, that homatropine produces 
in the frog a brief period of tetanus, followed by absolute muscular 
relaxation, with abolition of reflex and voluntary activity, followed in 
from six to eight hours, if the dose has been properly proportioned, by 

* Constitutional symptoms are readily produced by the free external use of belladonna 
plaster or ointment; and patients should always be warned to remove the plaster if dryness 
of throat or disorder of vision come on. For eases of poisoning in this way, see N. Y. Med. 
Record, Jan. 1884, also Journ. Amer. Med. Assoc., ii. 122. 



232 


GENERAL REMEDIES. 


return of voluntary movements, associated with tetanic spasms of 
great intensity. The convulsive movements and the paralysis are, 
according to De Schweinitz and Hare, of spinal origin, as the nerve- 
trunks and muscles are not affected. The cause of death is centric 
respiratory paralysis.* 

The action of homatropine as a mydriatic has been studied especially 
by Chas. A. Oliver {Amer. Journ. Med. Sci., July, 1881), Hr. S. T. Risley 
{Trans. Amer. Ophthal. Soc ., 1888), Hr. Jackson {Med. News , July 24, 
1886), and Hrs. He Schweinitz and Hare. The influence of the alka¬ 
loid upon the eye is practically identical with that of atropine, except 
that it is somewhat more feeble and is much more temporary. The 
pupil begins to dilate in from seven to twenty minutes after the instil¬ 
lation of the drug, and accommodation fails in from forty to ninety 
minutes: in from one to seventy-two hours the recovery is complete. 
According to Hr. He Schweinitz, a solution of one in eighty is suf¬ 
ficiently strong to paralyze accommodation completely, provided it be 
dropped repeatedly into the eye. AVhen it is desired simply to dilate 
the pupil for ophthalmoscopic examinations, a single application of a 
solution of four grains to the ounce suffices. Homatropine as a prac¬ 
tical mydriatic is greatly superior to atropine, not only because vision 
becomes normal in a few hours, but also because it is less irritating to 
the conjunctiva and much less prone to produce serious systemic dis¬ 
turbance. In fact, no further general effect than a little slowing of 
the pulse has as yet been noted after its most repeated use. 

STRAMONII FOLIA--STRAMONIUM LEAVES. U.S. 

STRAMONII SEMEN—STRAMONIUM SEED. U.S. 

The leaves and seeds respectively of the Hatura Stramonium, or 
Jamestoicn Weed, a coarse, bushy, annual herb, three or four feet high, 
growing in waste places both in this country and in Great Britain, and 
readily distinguished by its large, funnel-shaped, whitish, fetid flowers, 
and its quadrivalve spinescent capsules. The leaves are large, smooth, 
ovate, irregularly sinuate, with large acute teeth. The seeds are small, 
brownish black, reniform, with a feebly-bitterish narcotic taste. The 
active principle is an alkaloid which was discovered by Geiger and 
Hesse, and named Daturine , but which, according to Ladenburg, is a 
mixture of atropine and hyoscyamine. 

Physiological Action. —The physiological evidence as to the iden¬ 
tity of daturine and atropine is in strict accord with the chemical proof. 
The symptoms of poisoning by stramonium differ in no respect from 


* Dr. Wm. Mackintosh, in experiments made in the laboratory of the University of Penn¬ 
sylvania (unpublished Inaug. Diss., 1883), obtained results at variance with those that are 
cited in the text. He found that the conducting-power of the motor nerves is much depressed 
by homatropine, and that tying an artery prevents development of palsy in the limb, also that 
the pneumogastrics are paralyzed. The plausible explanation of these contradictory results 
is that Dr. Mackintosh used an alkaloid contaminated with atropine. 



DELI RIF A Cl ENTS. 


233 


those of belladonna-poisoning, although Laurent (Be VIlyoscyamine et 
de la Baturine, These, Paris, p. 22, 1870) asserts that irregularity of the 
heart’s action is more marked under the influence of stramonium. The 
same accelerated pulse, the same elevation of temperature, the same 
wild delirium, the same increased frequency of respiration, the same 
widely-dilated pupils, the same red efflorescence on the skin, the same 
restlessness or convulsions, occur in both cases, and, when the dose has 
been sufficiently large, end alike in abolition of the functions of circu¬ 
lation, respiration, and innervation,—stupor, general paralysis, weak, 
rapid, thready pulse, threatened asphyxia, constituting the phenomena 
of the closing scene in poisoning from either narcotic. 

The most careful, minute investigation of the physiological action of 
daturine which I have met with is that of Charles Laurent, already 
quoted. In his experiments that observer found that under the micro¬ 
scope the capillaries of the frog’s web could be seen to contract upon 
the application of daturine, even after division of the nerves of the limb; 
that the pulse-rate and arterial tension are both augmented by small 
doses of the poison, but that by large doses the arterial tension is 
diminished, although the pulse is still increased in frequency; that 
when the heart is completely separated from all connection with the 
central nervous system, daturine reduces the number of its beats: that 
respiration is accelerated by the alkaloid, even after section of the 
pneumogastrics; that by moderate doses of the alkaloid the conducting 
power of the sensory or of the motor nerves is not destroyed ; that the 
muscular contractility is not affected; that small doses increase, large 
ones diminish, intestinal peristalsis. Elaborate discussion of these facts 
seems unnecessary. It is seemingly demonstrated, both from a chemi¬ 
cal and from a physiological point of view, that daturine and atropine 
are identical. 

Therapeutics.— Stramonium may be used to meet precisely the same 
indications as belladonna. It has been especially employed in spasmodic 
asthma , chiefly in the form of cigarettes made by rolling up the dried 
leaves. These are often very efficient when there is no organic disease; 
but their use requires some caution, as very alarming symptoms, if not 
fatal results, have been produced by them. In the form of cataplasms, 
stramonium leaves are often applied with advantage to painful local 
inflammations , inflamed hemorrhoids , etc. 

Administration.— The officinal preparations of stramonium are all 
made from the seeds. They are the extract (Extractum Stramonii, U.S.), 
dose, one-fourth to one-half grain; the tincture (Tinctura Stramonii — 
1 to 10, U.S.), dose, ten to twenty minims; and the fluid extract ( Ex¬ 
tractum Stramonii Fluidum, U.S.), dose, one to two minims. 

Toxicology.— Accidental poisoning, especially of children, by stra¬ 
monium, is very common. In all points, as regards both symptoms and 
treatment, stramonium-poisoning and belladonna-poisoning are alike. 




234 


GENERAL REMEDIES. 


HYOSCYAMI FOLIA—HYOSCYAMUS LEAVES’. U.S. 

Hyoscyamus niger is a coarse herbaceous biennial, indigenous in 
England, and naturalized in the Northern United States. The leaves, 
which alone are officinal, are large, oblong-ovate, deeply sinuated, and 
very hairy. In 1821 Peschier announced the existence of an alkaloid in 
hyoscyamus, but it was not until 1833 that Geiger and Hesse succeeded 
in obtaining it pure. According to Geiger, when slowly crystallized, 
Hyoscyamine occurs in transparent needles, and in star-shaped or bushy 
clusters of crystals. According to the recent researches of Ladenburg, 
hyoscyamus contains two alkaloids: one is crystallizable, has the same 
chemical formula as atropine, and constitutes the crystalline hyoscyamine 
of commerce, and its sulphate is the Hyoscyamince Sulphas of the U.S. 
Pharmacopoeia; the other is amorphous, constitutes the amorphous hyos¬ 
cyamine of commerce, and, although it has the same chemical formula 
as hyoscyamine, is diverse from it; to it Ladenburg gives the name of 
hyoscine. Its salts are crystallizable. 

Physiological Action.— Both Schroff and Diillenberg have noticed 
in man, as the result of the ingestion of hyoscyamus, diyness of the 
throat and mouth, brief sinking of the pulse-rate, followed by increased 
frequency, mydriasis, giddiness, muscular weakness, and insecurity of 
gait. The experiments of Schroff, of Laurent, and especially of Harley 
(The Old Vegetable Neurotics), indicate that hyoscyamus is much more 
of a hypnotic than is belladonna. Yet Harley’s recorded observations 
would seem to show that in some individuals hyoscyamus induces in¬ 
somnia. According to Harley, the primary sinking of the pulse is much 
more marked after hyoscyamus than after its sister-narcotic. Laurent 
(De VHyoscyamine et de la Daturine , p. 15) affirms that the delirium 
caused by hyoscyamus is calm, while that produced by belladonna is 
fui’ious; but on page 19 of his book is recorded a case of henbane¬ 
poisoning in which the delirium was “furious.” Schroff (Wochenbl. 
der Zeitschr. der Gesellsch. der Aerzte zu Wien, 1865) asserted that pneu¬ 
monia is a constant and even characteristic lesion of hyosejmmus- 
poisoning in the rabbit; but Lemattre ( loc . cit.) has never seen more 
than little scattered points of hypenemia; and in Laui-ent’s experience 
even these have always been absent. 

In the elaborate research of Laurent it was found that the capil¬ 
laries of the frog’s web contracted after the local application of hyos¬ 
cyamine, even when the nerves had been previously severed, and also 
after the hypodermic use of the poison; that small doses augmented 
both the pulse-rate and the arterial tension, while large doses increased 
the former and diminished the latter; that the direct application of the 
alkaloid to the heart produced a rapid diminution of the number of its 
beats; that moderate doses increased the rapidity of respiration even 
after section of the pneumogastrics; that upon the nervous system, the 
muscles, and the intestines, the action of hyoscyamine was the same as 


DELI RIF A Cl ENTS. 


235 


that of daturine. The more important of these conclusions were also 
experimentally arrived at by Heilmann ( Beitrage zur Kenntniss der 
physiol. Wirkungen des Hyoscyamins, etc., Jena, 1873). Dr. R. Gnauck 
found ( Verhandlung. d. Physiolog. Gesellsch. zu Berlin, Aug. 1881) that 
hyoscyamine agrees with atropine in its action upon the vagus and 
heart-muscle, but is less powerful and persistent in its influence, and 
also acts as a powerful soporific: it further appeared especially to dilate 
the internal abdominal vessels. 

Therapeutics. —Hyoscyamus may be used to fulfil any of the indi¬ 
cations for which belladonna is employed. Clinical experience appears 
in a measure to bear out the assertions of various authorities as to the 
superiority of hyoscyamus as a hypnotic. It has been much employed 
by alienists in various forms of delirious insanity ( West Riding Lun. 
Asyl. Med. Reports, v.; London Tract., xvii. 17, xx. 85; Lancet, 1879, 
ii.; Archives of Med., 1880). Many of them claim that hyoscyamine 
has a very special calmative effect. The diagnosis and treatment of 
hyoscyamus-poisoning are identical with those of belladonna-poisoning. 

The preparations are the alcoholic extract (Extractutn Hyoscyami 
Alcoholicum, U.S.—dried leaves), dose, one to three grains, and the 
tincture ( Tinctura Hyoscyami, U.S.—dried leaves 1 to 6.66), dose, half a 
fluidrachm to two fluidrachms. 

Before we can reach positive results with hyoscyamus it is neces¬ 
sary that the isolated, crystallized alkaloids be separately studied. Dr. 
J. C. Shaw ( Journ. Nerv. and Ment. Lis., vii. 27) has recently partially 
studied crystallized and presumably pure hyoscyamine, and found that 
it affects the system of voluntary movement and the circulation, in¬ 
cluding the heart and the vaso-motor system, exactly as atropine does. 
In a single experiment the respiration did not seem to be affected as by 
atropine; but this is contradicted by results arrived at by previous ex¬ 
perimenters, and needs confirmation. Upon man Dr. Shaw believes, as 
do many other alienists, that hyoscyamine acts as a soporific. He states 
that it is less powerful as a mydriatic than is atropine, and that it dimin¬ 
ishes the respiratory rate. It must be remembered that these studies 
have been made upon lunatics; before the conclusions can be accepted 
as established, much more elaborate experimental researches are neces¬ 
sary, also studies upon normal individuals, and especially contrasting 
studies made with atropine and hyoscyamine upon maniacs; by the 
use of alternate doses upon the same individual any difference of action 
of the two drugs could readily be detected. It should also be remem¬ 
bered that in his studies upon normal men Dr. Richter noted no ten¬ 
dency to sleep ( Neurolog. Centralbl., i. 294). 

In a careful comparative study of hyoscyamine and atropine upon 
a case of acute mania by Professor Sydney Ringer, the two alkaloids 
were found to act practically alike ( Practitioner, March, 1877). Com¬ 
mercial hyoscyamine was formerly very impure, and a grain has been 


236 


GENERAL REMEDIES. 


given with impunity; but one-fortieth of a grain of the pure alkaloid 
has produced violent poisoning ( Lancet , 1879, i. 474). 

The fact that numerous observers have asserted that the impure 
amorphous hyoscyamine of commerce is more powerful than the pure 
crystallized alkaloid led me to believe that hyoscine, which constitutes 
a large portion of the so-called impure hyoscyamine, must be diverse in 
its action from hyoscyamine. Acting upon this, in 1884 I made a 
careful physiological study of hyoscine ( Therap . Gaz., Jan. 1885).* In 
the frog it produces a general motor and reflex paralysis, progressively 
increasing until death from failure of respiration. When recovery 
occurs, there is no stage of tetanus following the palsy. Neither the 
muscles nor the motor nerves are sensibly affected, and the paralysis is 
dependent upon depression of the motor centres of the spinal cord. 
No evidence could be obtained of affection of the sensory side of the 
nervous system. In mammals, the symptoms produced are loss of 
muscular power, disturbance of respiration, and marked tendency to 
stupor, with finally death by asphyxia. The alkaloid has very little 
effect upon the circulation, though after enormous doses when life is 


• Partial physiological studies of hyoscine have recently been made by Gley, Rondeau, 
Mairet and Combemale ( Compt.-Rend. Soc. Biolog., 1887), A. Sohrt ( Liang. Disn., Dorpat, 
1886), Claussens ( Inaug . JDiss., 1883), and Robert (Archiv /. Exper. Path. Pharm., 1887), 
the paper by Robert being apparently a restatement of the work done by his pupil 
Sohrt. Mairet and Combemale found that monkeys when poisoned by it gave evidences of 
the presence of hallucinations, such as are sometimes produced in man. The results obtained 
by the other investigators are in some points so different from those which I arrived at myself 
as to indicate that we were working with materials which were not exactly the same. The 
separation of hyoscyamine from hyoscine is so difficult that I cannot help suspecting that much 
that is sold often as pure hyoscine is frequently contaminated with the other alkaloid, and 
that discordant physiological and therapeutic results have been thus entailed. Claussens, like 
myself, found that hyoscine does not paralyze the pneumogastric nerve. P. Rondeau affirms 
that he has seen such paralysis caused by very large doses. Sohrt and Robert came to a similar 
conclusion, Robert stating that when hyoscine is placed directly upon the heart of the frog 
which has suffered diastolic arrest from muscarine systolic contractions are re-established, and 
also that when it is applied to the exposed heart of the frog it prevents the production of 
diastolic arrest by galvanization of the vagus centre. In further experimentation upon dogs 
and cats, it was found that when the vagus with its accompanying nerves was cut galvanization 
of the central end caused no sinking of the blood-pressure if hyoscine had been previously ad¬ 
ministered, and Robert deduces from this that hyoscine paralyzes the vagus nerve. The experi¬ 
ment evidently proves no more than that under the influence of hyoscine the depressor nerve 
is no longer able to cause vaso-motor dilatation. It is possible that directly applied to the 
frog’s heart hyoscine may paralyze the vagi, and yet its influence upon those nerves be so 
slight as not to be apparent when the alkaloid has been absorbed and is acting upon the whole 
organism. Almost all clinical observers have noted that the pulse becomes slower rather than 
more rapid under the influence of hyoscine, and this assuredly shows, too, that the drug has 
no marked paralytic action upon the vagus, for the pulse of vagus-paralysis is of necessity 
very rapid. Robert also found that hyoscine has no influence upon the spinal cord of the 
frog when given in doses of one-five-hundredth part of its weight; but, as the paralyzing in¬ 
fluence of the drug in my experience was marked with one-one-thousandth part of the frog’s 
weight, while one-five-hundredth part caused complete loss of reflex activity with absolute 
paralysis, and death from respiratory paralysis, it seems most probable that Robert, or rather 
his pupil, Sohrt, had a mixture of hyoscyamine and hyoscine. 



DELI RIF A CIENTS. 


237 


maintained by artificial respiration the vaso-motor system is finally 
paralyzed. On the heart itself hyoscine acts as a very feeble depress¬ 
ant ; it does not paralyze the pneumogastrics. In man the symptoms 
which are produced by decided doses are dryness of the mouth, flushing 
of the face, great sleepiness, associated in some cases with semi-delirious 
mutterings, and a feeling of giddiness like that of intoxication. The 
respirations are lessened in frequency, and the pulse-rate is also some¬ 
what diminished; mydriasis is usually, but not always, pronounced. 
After very large doses the symptoms mentioned are more intense; the 
pulse becomes slow and full, but, according to the sphygmographic 
tracings of Dr. J. B. Andrews, without alteration of tension, the pupils 
dilated, the mouth and throat excessively dry, and the voice hoarse or 
even partially suppressed, probably from paralysis of the vocal cords. 
The respirations are slow and full, and are said by Dr. II. M. Wetherill 
(Therap. Gaz ., i. 199) to be sometimes Cheyne-Stokes. The face and 
the general surface of the body are suffused, muscular relaxation is 
pronounced, and loss of co-ordination usually very evident. The skin, 
so far from being abnormally dry, is commonly bathed in perspiration. 
Several observers assert also that there is a rise of temperature. Dr. 
H. A. Hutchinson (Alienist and Neurologist , iii. 539) took a quarter 
of a grain of very impure hyoscine: quiet coma with entire muscular 
relaxation was produced, and lasted eleven hours. It is evident that in 
man, as in animals, the motor tract of the spinal cord and the cerebral 
cortex are especially affected by this alkaloid, which is also a respira¬ 
tory paralyzant. No case of fatal poisoning is on record. On the other 
hand, very severe symptoms are alleged by several physicians to have 
followed the use of very small doses of the drug. Dr. O’Hara ( Therap. 
Gaz ., ii. 26) saw one-ninety-sixth of a grain administered hypoder¬ 
mically produce very severe disturbance, lasting for twenty-eight hours, 
with total lack of remembrance of occurrences which took place during 
the seven hours following the injection; while Dr. Root ( Therap. Gaz., 
vol. ii.) asserts that one-three-hundredth of a grain given by the 
mouth produced violent poisoning, and even one-twelve-hundredth very 
pronounced symptoms. The dispensing of these exceedingly minute 
quantities of a drug requires so much care that it is extremely prob¬ 
able that more of the alkaloid was given than is alleged. A disagree¬ 
able symptom which has been noted by several observers, and which 
I myself have seen produced by hyoscine, is paralysis of the pharynx, 
and probably also of the laryngeal muscles. The importance of this 
action was made very apparent to me by my noticing it in a case of 
malignant scarlet fever with great diphtheritic exudation, in which the 
hyoscine was given with immediate relief of the persistent delirious 
insomnia, but in which under the influence of the drug the dyspnoea 
rapidly increased in intensity and in an hour or two ended in death. 

According to Mr. John Tweedy ( Lancet , Dec. 1886), the hydro- 
bromate of hyoscine is a very powerful local mydriatic, a half of one 


238 


GENERAL REMEDIES. 


per cent, solution rapidly paralyzing accommodation and dilating the 
pupil. It is said that it does not produce any irritation, and that its 
maximum effects are reached in one-third the time necessary for those 
of atropine, and are more permanent and less affected by eserine. MM. 
E. Gley and P. Eondeau ( Compt.-Rend. Soc. Biol., 1887, iv. 56) have 
found that the mydriasis is not prevented by previous destruction of 
the cervical sympathetic in the rabbit, and that irritation of the sym¬ 
pathetic nerve will increase the dilatation. 

The results of my experiments with hyoscine upon the lower animals 
led to its use as a hypnotic, and it has proved itself a valuable thera¬ 
peutic agent, especially useful in cases of insomnia with delirious ex¬ 
citement, such as occurs in acute mania and in other foi’ms of insanity. 
Under these circumstances its effects in producing sleep are often ex¬ 
traordinary : it has been in my expei’ience especially valuable in those 
cases in which morphine intensified the excitement, and I have frequently 
seen it succeed after the failure of both chloral and morphine. In de¬ 
lirium tremens it in some cases has acted most favorably. Since the 
publication of my memoir, hyoscine has been very extensively used, 
with in most cases favoi’able results. (See J. B. Andrews, Amer. Journ. 
Insan., Oct. 1885; Dr. J. Mitchell Bruce, Bond. Pract., vol. xxxvi., 
1886, p. 321: also various papers in Therap. Gaz., vol. ii.) As early as 
1881 Professor Edlesen (Centralbl. f. Med. Wissensch., 1881, 416) stated 
that hyoscine is useful in asthma, and also in whooping-cough, and Dr. 
Eudolph Gnauck ( Centralbl. f. Med. Wissensch., 1881, 801, Charite An- 
nalen, 1882, 488), that it had a powerful hypnotic influence. 

The insomnia which is especially relieved by hyoscine is that which 
is connected with cerebral excitement when sleep is banished by a 
continual whirl of thoughts or mental images. Excellent effects are 
sometimes achieved in cases of nervous excitement with or without 
insanity, by giving very minute doses of hyoscine, which allay the ex¬ 
citement and produce quiet without causing sleep. Dr. Bruce ( loc. cit.) 
and Tirard ( Practitioner, Feb. 1887) assert as the result of their experi¬ 
ments that hyoscine is an entirely safe hypnotic in cases of severe 
kidney-disease when morjihine cannot be employed. Dr. Bruce also 
states that he has used the drug with good results when an exceedingly 
feeble condition of the heart forbade chloral. 

Probably through its influence upon the spinal centres hyoscine is a 
most useful remedy in all cases of sexual excitement, such as nympho¬ 
mania, spermatorrhoea, and allied affections. It is the most certain 
remedy that we have in ordinary cases of over-frequent seminal emis¬ 
sions, which can almost invariably be controlled by the administration 
of -J- 5 TJ- to -gV of a grain on going to bed. I have obtained the most 
pronounced relief in paralysis agitans attended with much aching pain 
by the use of hyoscine, and Erb has recently praised the drug highly 
in this disease ( Zeitschr.f. Therap., Aug. 1887). In most cases it should 
be given only at bedtime, as it is simply a palliative, and if used con- 



DEL I RIF A CIENTS. 


239 


stantly is prone to lose its power. Erb has used it with advantage in 
various spasms. In one or two cases of spinal accessory spasm it has 
in my hands failed. 

Hyoscine very rarely if ever causes other disagreeable after-effects 
than a little dryness of the throat, although occasionally some headache 
has been noted. Nausea, constipation, or other disturbance of the ali¬ 
mentary canal is never produced. The action of hyoscine given hypo¬ 
dermically is manifested inside of ten minutes, and lasts from about six to 
eight hours. In severe excitement, especially that of violent insanity, 
the dose should be repeated every six or eight hours. The remedy 
being free from irritant properties, no local ill effects follow its hypo¬ 
dermic administration. The dose for hypodermic use may be set down 
at from Fir to of a grain. Excessive susceptibility to the action 
of hyoscine being a not infrequent idiosyncrasy, it is best to give at 
first amounts below the minimum dose here stated. The tastelessness 
of hyoscine makes it exceedingly easy to administer it to insane or 
other patients without their knowledge. 

Hyoscine is with difficulty separated from its sister alkaloid hyoscy- 
amine, and it is essential for successful results that the practitioner 
have a pure article of hyoscine. In my own practice I rely solely upon 
that made by Merck, of Darmstadt. 

ERYTHROXYLON—COCA. U.S. 

The leaves of the Erythroxylon Coca, a South American shrub, which 
is very largely cultivated in Peru and neighboring countries, resemble 
in size and shape those of the tea, but are not dentate, and are distin¬ 
guished from most medicinal leaves by a slightly-curved line, running 
from the base to the apex, on each side of the midrib, and produced by 
the peculiar folding of the leaf in the bud. In 1855, Gfardeke discov¬ 
ered in coca an alkaloid to which he gave the name Erythroxyline; but 
this principle was first thoroughly studied by Dr. Albert Niemann, from 
whom it received the name Cocaine , by which it is now usually known. 
It occurs in colorless, transparent prisms, soluble in seven hundred and 
four parts of cold water, and forms with the acids very bitter, soluble, 
crystallizable salts; besides cocaine, the leaves contain a peculiar tannin, 
known as coca-tannic acid. 

Physiological Action.— From the days of the Incas the leaves of 
the coca plant have been enormously used by the natives of Western 
South America as a stimulant, and it is stated that about forty million 
pounds of them are annually harvested. Mixed with ashes or a little 
lime, they are chewed, and are said to increase greatly for the time 
being the muscular strength and endurance. Although coca is thus 
employed habitually, our knowledge of its action upon the human 
organism is very incomplete, and but few scientific observers have given 
detailed reports of the symptoms it causes. Moderate doses appear 
to increase temporarily, to a very extraordinary degree, both physical 



240 


GENERAL REMEDIES. 


and mental power. The most important account of its action upon 
the human being that we have is that of M. Montegazza; but all in¬ 
vestigators concur in praising the peculiar sense of calm and happi¬ 
ness, the insensibility to fatigue, and the increase of bodily and mental 
activity which the drug produces. 

Montegazza states that when he took two hundred grains of the 
leaves he was in a short time plunged into a condition of peculiar 
physical beatitude, in which he seemed to be isolated from the rest of 
the world and to live in a peculiar atmosphere of active calm. In a 
little while there came also a sense of plenitude of power, which was 
accompanied by a real increase of physical ability, so that gymnastics 
which in his ordinary condition were impossible to him became easy. 
This state was succeeded by a natural profound sleep, lasting sometimes 
the whole of twenty-four hours. After very large doses of coca, in Dr. 
Montegazza’s case, a peculiar series of symptoms occurred to which the 
name of “ cocaleine intoxication” was given. Thus, on one occasion he 
took thirty-five grammes, and an hour later nine grammes, etc., until 
he had taken in the course of two hours sixty grammes in all. The 
heart, which after the earliest dose had been slow in its action, directly 
after the second dose suddenly became rapid and very violent in its 
beats; but at the end of the two hours the palpitations had ceased, 
although the pulse was still one hundred and twenty-eight per minute. 
There was now a condition of intoxication similar to that which is pro¬ 
duced by hashish. M. Montegazza was possessed by a feeling of in¬ 
tense beatitude and inner joyousness, while a succession of visions and 
phantasmagoria, most brilliant in color and form, trooped rapidly before 
his eyes. He seemed to himself to look upon a world of shifting and 
incessant activity, as into a kaleidoscope. He rapidly passed into a 
delirious condition, in which he appeared to himself to be unconscious, 
although when addressed he would answer rationally. To his own con¬ 
sciousness he was, as it were, buried in a revery, or perhaps a more ac¬ 
curate description would be to say that he felt as though, by a sudden 
rush of intellectual and emotional life, he was carried out of himself, 
and knew not whether he was in or out of the body. An hour or two 
later he was sufficiently calm to say to his friends “ that God was un¬ 
just, in that he had made man to live without eating coca. I prefer a 
life of ten years of coca to one of a thousand years without it.” As 
this state was passing off, he was seized with an irresistible desire to 
reproduce its delirium by taking more coca. Finally, however, he fell 
into a condition of sleep, which lasted only three hours. After this he 
was able to resume at once his ordinary occupations, and offered no 
physical evidences of his coca debauch. 

The moderate daily use of coca, according to our best information, 
is not injurious, and increases the working powers; but, according to 
Professor Poeppig, the habit of the excessive use is readily formed, and 
produces very serious results. The first symptoms are usually those of 


DELIR1FA Cl ENTS. 


241 


disorder of the digestive organs. Little by little the power of digestion 
is lost; an incurable insomnia is developed, emaciation becomes extreme, 
ascites appears, and the patient finally dies in a condition of general 
marasmus. Other authors especially dwell upon the enfeeblement of 
the intellectual faculties as very marked in those who use the stimulant 
to excess. Dr. Tschudy states that the inveterate coca-chewer can be 
recognized by his uncertain step, his general apathy, his sunken eyes 
surrounded by a deep purple aureole, his trembling lips, his green 
encrusted teeth, and his excessively fetid breath, with the peculiar 
blackness about the corners of the mouth. 

Already in this country victims of the cocaine habit have in a 
number of cases presented themselves for treatment. Usually the 
cocaine has been taken as a substitute for or an aid to morphine. It 
is, I think, perfectly safe to withdraw the cocaine at once. In a case 
under my own care, in which fifteen grains had been taken hypoder¬ 
mically daily, the abrupt withdrawal was followed simply by diarrhoea, 
dyspepsia, and nervous depression, which subsided in the course of two 
or three days. (For a collection of cases see Dr. Grundlach, Schmidt’s 
Jahrh., Bd. ccxii., 1886.) 

Pronounced aphrodisiac properties have been attributed to coca, but 
they seem to rest rather upon tradition than upon demonstrated ex¬ 
perience. According to M. Unanue, the ancient inhabitants of Peru 
represented Yenus by a female figure with a coca-leaf in her hand, and 
the coca still plays an important part in the nuptials of the Indians. 

It has been affirmed by Tschudy and Unanue that coca is able to 
take the place of food; but this is clearly not the case. Dr. Weddell 
himself states that although an Indian chewing the coca could go on 
foot many hours without fatigue and without food, yet at the end he 
would eat more at one repast than he himself Avould take in two days. 
He accords with Bibra ( Die Narkot. Genussmittel, 1855) in stating that 
the coca has the power of putting aside for some time the sense of 
hunger. While, however, it may mask the appetite, it certainly does 
not nourish the body, and it is, indeed, most probable that the absence 
of hunger is the outcome of a local benumbing of the gastric nerves. 
Thomas Moreno y Maiz (These, Paris, 1868) made several crucial ex¬ 
periments by keeping animals in pairs without food, and giving to 
one coca freely. These experiments have been repeated by B. von 
Anrep (Pfliiger's Archiv, xxi., 1880), and in every case the animal which 
received the coca died at least as early as its mate. 

The chief physiological papers upon cocaine, which I have studied 
in the original, are those of B. von Anrep (Arch. f. Gesammt. Physiol., 
Bd. xxi., 1880), U. Mosso (Arch. Exp. Path. Pharm., Bd. xxiii.), H. Alms 
(Arch. Physiol., 1886, Suppl. Bd.), and Dr. I. Ott (Toxicological Studies , 
Phila., 1874). I have also seen the abstracts of the papers by Nikolsky 
and Dannini, contained in the memoir of Von Anrep. 

It may in the first place be considered settled that very small doses 

16 


242 


GENERAL REMEDIES. 


(one to three one-hundredths of a grain of cocaine) produce in the frog 
no other symptoms than some evidences of excitement. After doses of 
from one-tenth to one-fiftieth of a grain the frog becomes quiet, with an 
apparent increase, however, in the reflex activity, sometimes amounting 
to tetanus, followed by increasing palsy and failure of the respiration ; 
very large doses produce symptoms of paralysis. 

In the domestic animals the symptoms vary. In the rabbit there 
is first a peculiar state of quiet, followed in a few moments by a con¬ 
dition of great excitement, in which the animal springs and jumps about. 
A few minutes later the rabbit again becomes quiet, and now, although 
trembling much, is so weak that he moves with difficulty. The trem¬ 
blings increase until they merge in convulsive movements of the legs, 
while at the same time there is partial paraplegia; pendulum movements 
of the head are very marked, and finally epileptiform convulsions appear, 
while simultaneously a peculiar tetanic rigidity seems to indicate spinal 
excitement. The lethal dose for a rabbit is put at a grain and a half per 
kilo. Dogs and cats are said to be more susceptible to the action of co¬ 
caine than is the rabbit, and to suffer similar symptoms, but especially 
with the dog the evidences of mental excitement are more pronounced. 

Nervous System .—The most susceptible portion of the body to the 
action of cocaine is the cerebrum. The peculiar sense of calm which 
follows moderate doses of the drug is evidently the result of the action 
on the brain, which eventuates, after a sufficient dose, in the peculiar 
ecstas} 7 so graphically described by Montegazza. According to the de¬ 
scription of Yon Anrep, this delirium is almost equally pronounced in 
the dog: thus, an habitually very quiet animal, directly after the injec¬ 
tion of the cocaine, will begin to dance and leap, never standing still 
for a moment, and continually circling around the experimenter. The 
movements are not at all those of convulsions, but voluntary, and accom¬ 
panied by every expression of joy and exhilaration. This may continue 
for hours, the animal then becoming gradually quiet, and passing finally 
into his normal condition. If instead of a moderate dose a toxic one 
has been given, there is first a period in which the animal is very rest¬ 
less, but seems full of terror and anxiety ; the least sound frightens him, 
causing him to tremble and to drop his tail between his legs. He does 
not appear at this time to know his master. Ehythmical movements 
of almost all portions of the body accompany this state. Fifteen or 
twenty minutes later the mental condition alters, and the dog becomes 
apparently full of joyous excitement. He barks loudly, runs from one 
person to another, licking them, and giving all the characteristic signs 
of joy and pleasure. After a few moments this condition gives way to 
one of increasing feebleness : the dog gradually becomes unable to 
move, rhythmical movements, cramps, and convulsive symptoms ap¬ 
pear; the pendulum-like swinging of the head becomes very violent, 
and at last narcosis, with epileptiform convulsions, develops. It is evi¬ 
dent that many of these symptoms are psychical. 


DELIRIFA CIENTS. 


243 


B. von Anrep believes that the drug has a very distinct and peculiar 
influence upon the semicircular canals , thereby causing the peculiar pen- 
dulum-like motions of the head, the lack of co-ordination, and the rolling 
convulsions especially seen in doves. 

Spinal Cord .—According to the researches of Yon Anrep, the con¬ 
vulsive movements are of cerebral origin, and are arrested by section 
of the spinal cord; but the experiments of L. I. Tumass ( Arch.f . Exper. 
Path. Pharm., xxii.) indicate that they do not arise in the psycho-motor 
centres of the brain-cortex, since he found not only that the local ap¬ 
plication of cocaine lessens the irritability of these centres, but also 
that during the convulsive stage of cocaine-poisoning the centres are 
less sensitive than normal. Dannini appears, however, to have found 
that the section of the cord did not prevent convulsions in the hind 
feet, and the experiments of Mosso show that when the cord is cut in 
the dog and the animal cocainized, the irritation of the nerve-trunk or 
of the surface will produce in a little while general muscular rigidity. 
Both Mosso and Yon Anrep are in accord with other observers in stating 
that reflex activity is at first increased by cocaine, and the evidence 
seems to show that while the convulsive movements of the poisoned 
animal originate chiefly in the brain, yet there is a primary stage of 
excited reflex activity, the result of a direct action upon the spinal 
cord. The motor paralysis and the loss of reflex activity which finally 
occur in cocaine-poisoning are probably in part the result of an influ¬ 
ence upon the nerves ; but that they are chiefly due to a direct sedative 
action upon the spinal cord seems to follow from the experiments of 
Mosso, who found that when he so bound the hind legs of the frog as 
to prevent the access of cocaine there was a rapid loss of reflex activity, 
and indeed a complete paralysis, at a time when both the motor and 
the sensory nerves were still intact. 

An observation made at a certain stage of the poisoning by Dr. Ott, 
viz., that irritation of the posterior columns of the spinal cord produces 
no effect, while a prick of the anterior column is followed by the usual 
result, shows that there is the same difference in action upon the sen¬ 
sory and motor tracts as upon the corresponding nerve-trunks. 

Nerves .—Although cocaine appears in general poisoning to have a 
very distinct spinal action, almost all observers agree that the sensory 
nerves after sufficient doses are finally paralyzed. The statements and 
experiments of Nikolsky, of B. von Anrep, and of Ott appear to prove 
that paralysis is preceded by increased functional activity. 

The motor nerves , according to Dannini, in the frog remain irritable 
until after death; but, according to Nikolsky, their functional activity 
is first increased and afterwards destroyed. Ott also asserts that co¬ 
caine depresses the motor nerves, and Moreno y Maiz found that when 
he tied the iliac artery of a frog on one side and administered cocaine 
anteriorly, there came a time when irritation of the poisoned limb 
caused no movement, while irritation of the protected extremity pro- 


244 


GENERAL REMEDIES. 


yoked very distinct general reflexes. At the same time there was 
diminished motility in the non-protected limb as compared with the 
protected one. These facts, of course, indicate that the drug finally 
depresses both motor and sensory fibres, but that its action upon the 
motor is subordinate to that upon the sensory nerves. Ott also noticed 
that there is a time in the poisoning when irritation of the central end 
of a cut sciatic nerve produces no response, while irritation of its 
peripheral end causes muscular action, and thereby confirms the view 
that the drug affects the sensory earlier and more powerfully than the 
motor nerves. 

These various statements are confirmed by the researches of H. 
Alms, who found (Archiv fur Phys ., 1886, Suppl. Bd.) that a five-per¬ 
cent. solution of cocaine in contact with the isolated ischiatic plexus 
of the frog caused absolute anaesthesia of the leg and apparent loss of 
motor power, the leg lying motionless and trailing behind. Neverthe¬ 
less strong irritation upon the front leg of the frog caused immediate 
movements which were shared by the cocainized hind leg, showing 
that the motor filaments were not paralyzed. The experiments of Alms 
indicate that the extreme peripheral filaments of the nerve are first 
affected, since at a certain period most severe irritation of the skin pro¬ 
duced no pain in the poisoned rabbit, although the injection of irritating 
materials caused evidently violent pain. 

Circulation .—The work which has been done to determine the action 
of cocaine upon the circulation, although considerable in quantity, has 
been so fragmentary, and the results achieved are apparently so discord¬ 
ant, that no positive conclusions are at present possible. The testimony 
seems to be concordant in showing that the influence of the poison upon 
the circulation is entirely subordinate to its action on respiration, the 
heart always continuing to beat after the arrest of respii’ation. Ac¬ 
cording to Yon Anrep, as well as to the earlier observations of Nikol¬ 
sky, the heart of the cocainized frog is gradually weakened and arrested 
in diastole; but Mosso found that minute doses of cocaine increased 
the rapidity and power of the systolic contractions in the cut-out frog’s 
heart, while larger doses caused systolic arrest. The suggestion offers 
itself that the diastolic arrest of the heart asserted to take place in 
general poisoning is the result of the long-drawn-out asphyxia; but Dr. 
H. Cr. Beyer ( Amer. Journ. Med. Sci., July, 1885) affirms that while 
small doses of cocaine increase the action of the isolated heart of the 
terrapin, large doses arrest it in diastole. 

In the earlier investigations of Ott, of Yon Anrep, and of Laborde, 
a rise in the arterial pressure followed the injection of cocaine into 
the circulation of the mammal. Although it is not positively stated in 
the text of the memoirs that the animals were not curarized, there 
seems to be little doubt that the experiments were made upon non-cura- 
rized animals. As cocaine disturbs the respiration, and also produces 
wide-spread muscular contractions, it is necessary to experiment upon 


DELI RIF A Cl ENTS. 


245 


animals whose respiratory and muscular systems are paralyzed in order 
to obtain accurate knowledge of the direct immediate action of the 
alkaloid upon blood-pressure, since asphyxia and muscular contractions 
notably increase blood-pressure. 

The expei’iments of Yulpian ( Compt.-Rend ., 1884, vol. ii. p. 885) and 
of Berth old ( Centralbl. Med. Wissensch., 1885, p. 435) do not satisfactorily 
determine the effect of cocaine in curarized animals. Yulpian obtained 
in a single experiment a very marked rise of the arterial pressure 
which was maintained for three minutes, when upon the injection of a 
second dose the pressure fell; while, according to Berthold, distinct per¬ 
manent elevation of the blood-pressure is never produced by cocaine 
in curarized animals, although in some cases he had noticed a slight 
rise lasting for one or two minutes. Large doses of cocaine cause a 
pronounced sinking of the blood-pressure. Mosso considers the fail¬ 
ure of the alkaloid to cause rise of the arterial pressure in the cura¬ 
rized animal to be owing to the curare “ paralyzing the influence” of 
the cocaine; but curare, unless given in overwhelming doses, does not 
affect either heart or vaso-motor system, and it is not probable that 
Berthold and Vulpian used the curare so unskilfully as sensibly to 
affect the circulation. After section of the spinal cord no rise of the 
arterial pressure is produced by cocaine (Dannini and Berthold). 
There is also great variance of testimony in regard to the effect of the 
alkaloid upon the pulse-rate and upon the vagi. Yon Anrep states 
that the pulse-rate is usually increased, but that this increase is not 
marked in rabbits, while in Ott’s experiments upon dogs the pulse 
usually becomes slower. Yon Anrep also states that the vagi are para¬ 
lyzed by large doses of cocaine, while Ott, Nikolsky, and Durdufi (Deutsch. 
Med. Wochenschr., 1887, 172) all declare that it does not affect the 
vagi at all, and Berthold states that previous section of the vagi has no 
effect upon the course of the symptoms caused by cocaine. Further, 
Mosso states as the result of experiments made with artificial circula¬ 
tion in extirpated kidneys that small doses of cocaine have no sensible 
effect upon the blood-vessels, while large doses paralyze them; but Dr. 
H. G. Beyer ( Amer. Journ. Med. Sci., June, 1885) found in his studies 
upon the terrapin that both large and small doses of cocaine produce 
contraction of the blood-vessels by a direct action. Durdufi affirms 
that marked narrowing of the vessels of the ear can be seen in the 
rabbit when cocaine is injected, but that if the sympathetic be pre¬ 
viously divided no distinct contraction will occur in the dilated vessels. 

It seems to me probable that cocaine has very little direct influence 
upon the circulation of the mammal; but a careful experimental re-study 
of the whole subject is urgently required. 

Muscles .—There is a distinct contradiction as to the effect of cocaine 
upon the striated muscles. Alms, Nikolsky, and B. von Anrep state 
that the latter are not affected by the alkaloid, while Ott affirms that 
it acts upon them like veratrine, and is confirmed in this by Buchheim 


246 


GENERAL REMEDIES. 


and Eisenmenger ( Pflanzenstoffe, 2d ed., 885). The tracings given by Ott 
would appear to prove that the muscular contraction is prolonged by 
cocaine, and can hardly be accounted for by a condition which M. J. 
Eossbach and B. von Anrep ( Pfluger's Archiv, xxi. 243) allege to be 
produced, viz., a peculiar extensibility of the muscle similar to that 
produced by curare, and, like it, caused by a lessening of muscle-tonus 
by paralysis of the peripheral nerve-endings. Professor Berthold has 
also found that the frog’s muscles are affected by the local application 
of cocaine ( Centralbl. Med. Wissensch,, 1885, 147) and we must conclude 
that cocaine, when brought in direct contact with the muscles, acts 
upon them, but that in general poisoning its influence is too slight to 
be readily apparent. 

Temperature .—Observers agree that there is during a certain stage 
of cocaine-intoxication a remarkable rise in the rectal temperature. 
According to Bennett, Ott, and Yon Anrep, this rise of temperature is 
preceded by a fall; in toxic cases the temperature appears again to 
become subnormal before death. Yon Anrep states that the skin-tem¬ 
perature is always elevated from the beginning. The rise in the rectal 
temperature reaches the maximum (1° C.) during the convulsive stage, 
but is not produced by the convulsions, as Dannini has found that it 
occurs in curarized animals. 

Elimination .—According to Moreno y Maiz, cocaine is eliminated by 
the kidneys. 

Urinary Secretion .—Dr. J. M. Da Costa states that the hypodermic 
injection of cocaine, in doses of one-half to one grain three times a day, 
markedly increases the flow of urine without altering its specific grav¬ 
ity (Med. News, xlviii. 679). According to Dr. Bignon, however, the 
single large dose of cocaine causes an anuria which may be followed 
by excessive secretion, or may be so prolonged as to cause uramiic 
symptoms (Journ. Amer. Med. Assoc., July, 1887). Further, both Drs. 
Ott and Atherton P. Mason ( Bost. Med. and Surg. Journ., Sept. 1882) 
found that when cocaine is taken habitually it not only lessens the 
secretion of urine but also markedly decreases the elimination of urea. 
Dr. Mason employed very large doses of cocaine during prolonged 
exercise. It is, therefore, very probable that this drug diminishes 
tissue-waste, although Dr. Mason himself states that Gazeau has 
obtained contrary results. In Dr. Ott’s experiments the urine became 
filled with crystals of oxalate of calcium. Tarchanoff has noticed 
sugar in the urine of poisoned animals, but Yon Anrep affirms that 
the sugar and the albumen, which is also frequently present, are caused 
by the asphyxia induced by the drug. 

Eye *—When a watery solution of cocaine is dnypped into the eye 


* The following comparison of the action of mydriatics was prepared at my request by 
Dr. Geo. De Schweinitz, of the eye clinic of the University Hospital: 

Atropine, daturine, hyoscyamine, hyoscine, and duboisine have each the power to dilate 



DELI RIF A Cl ENTS. 


247 


there occurs a slight contraction of the pupil, followed within a few 
minutes by dilatation. The first contraction is probably reflex and 
due to the irritation of the conjunctiva. The maximum dilatation for 
a four-per-cent, solution is usually reached about the end of the first 
hour; an hour later it has sensibly begun to decline, and in from twelve 
to twenty-four hours the pupil returns to normal. The dilated pupil is to 
some extent responsive to light, and the mydriasis is rapidly overcome 
by eserine. The dilatation is said, however (Edward Jackson, Med. 
News, 236), to be greater than that obtained by atropine or allied alka¬ 
loid, either of which effectually prevents the myotic action of eserine. 
The ocular tension is lowered rather than increased. The power of 
accommodation, while distinctly lessened in its range, is never entirely 
paralyzed. (Knapp, Cocaine, 1885.) Dr. Jackson affirms that cocaine 
causes a peculiar irregularity of the corneal surface tvhich is not due to 
any loss of epithelium, although it may proceed so far as to cause a nota¬ 
ble haziness. Wiirdinger produced distinct corneal opacity in the rabbit 
by repeated instillations of a five-per-cent, solution. It seems, however, 
probable that this opacity was the result of corneal inflammation duo 
to the inability of the anaesthetized eye thoroughly to protect itself: 
nevertheless, some oculists affirm that cocaine distinctly predisposes tho 
eye to excessive inflammation upon irritation or operative procedures. 

G-. N. Durdufi ( Deutsch. Med. Wochenschr., March, 1887) states that in 
dogs poisoned with cocaine not only is there dilatation of the pupil but 
also a manifest protrusion of the eyeball, with excessive opening of tho 
lids; phenomena which are similar to those that follow irritation of tho 
cerebral end of the divided sympathetic nerve in the neck, and which 
Durdufi concludes to be due to stimulation by cocaine of the sympa¬ 
thetic nerve-centres, because he has found that they are prevented by 


the pupil ad maximum. Because cocaine leaves the pupil responsive to light, and because its 
mydriasis is readily overcome by a myotic, like eserine, it has been classed as a feeble mydri¬ 
atic. Nevertheless, with it as wide a dilatation of the pupil may be obtained as with any of 
the five other drugs, provided the observation is made by a weak light and when convergence 
and accommodation are relaxed. Such precaution is unnecessary with the others. 

After mydriasis and ciliary paralysis are produced with atropine full accommodation is re¬ 
stored in from ten to fourteen days; with daturine in about ten days ; with hyoscyamine in from 
six to eight days ; and with duboisine in about four to five days. The duration of the mydriatic 
action of hyoscine resembles that of hyoscyamine. It is, however, a more powerful mydriatic. 
Dilatation of the pupil under the influence of cocaine declines markedly within an hour, but the 
return to normal is usually not complete until the end of twelve hours. 

Atropine, daturine, hyoscyamine, hyoscine, and duboisine all produce ciliary paralysis, 
and may hence be employed to correct anomalies of refraction; atropine and hyoscyamine 
should be preferred,—the former if the condition of the eye-ground calls for prolonged rest. 
When dilatation of the pupil is necessary in the treatment of inflammatory diseases of tho 
cornea and iris, atropine should be chosen. The great objection to the use of duboisine is the 
pronounced systemic disturbance which it occasionally produces. Cocaine is useless in the de¬ 
termination of errors of refraction, but is very useful as a dilator of the pupil for diagnostic 
purposes. 

Atropine certainly increases intraocular tension, so also probably do hyoscine, daturine, 
and hyoscyamine. Cocaine has the power to lower the tension of the normal eye. 



248 


GENERAL REMEDIES. 


section of the sympathetic nerve in the neck either with or without 
accompanying section of the oculo-motor nerve. He has further ex¬ 
perimentally determined that section of one-half of the spinal cord one 
and one-half centimetres from the point of the calamus does not inter¬ 
fere with the production of the cocaine phenomena in either eye, and 
therefore locates the ocular centre which is affected by cocaine in the 
medulla spinalis below the medulla oblongata. Until, however, the 
experiments of Durdufi have been confirmed by other observers, they 
cannot be received as conclusive, because they appear to be contradictory 
to the results obtained by the clinical use of cocaine, and are also in 
direct antagonism to the experimental results arrived at by Nikolsky, 
who states that after section of the sympathetic nerve in the neck 
cocaine does still dilate the pupil, and that when the pupil has already 
been dilated by cocaine section of the sympathetic nerve does not pro¬ 
duce contraction. Basing his conclusion upon his own observations, 
Nikolsky affirms that the dilatation of the pupil is not produced by 
stimulation of the sympathetic nerve at all. It is plain that the con¬ 
clusions of Durdufi and of Nikolsky are alike strongly opposed by the 
fact that cocaine dilates the pupil when applied locally to the eye, since 
this fact appears to prove that the dilatation is due to a peripheral and 
not a centric action. 

Respiration .—Small doses of cocaine increase distinctly the rapidity 
of the respiration, and in some cases also the depth (Yon Anrep and 
Mosso). After toxic doses the respirations become at first rapid and more 
shallow, then irregular with interruptions, after each of which the re¬ 
spiratory movements begin deep and slow, but become more rapid and 
shallow until the next stand-still. As Mosso found that after section of 
the vagi cocaine causes an enormous increase of the rapidity of the 
breathing and at the same time so modifies the rhythm that the expira¬ 
tion is no longer more quick than inspiration, it must be considered that 
the drug acts directly upon the respiratory nerve-centres as a respiratory 
stimulant. The first stimulant effect of cocaine upon the respiratory 
centres appears to be followed after fatal doses by a paralyzing influ¬ 
ence which leads to death from asphyxia. 

Intestines .—According to Yon Anrep, the intestinal peristalsis is 
markedly increased by moderate doses. After large doses this increase 
is followed by great sluggishness deepening into paralysis. Tarchanoff 
states that coca increases the mucous secretions, but Von Anrep affirms 
that it decreases them. 

Summary .—Cocaine is a cerebral stimulant, producing peculiar 
mental excitement, ending after large toxic doses in narcosis, with epi¬ 
leptiform convulsions, which are probably of cerebral origin. In the 
poisoning there is at first increased reflex activity, followed by paralysis 
of voluntary motion and of reflex activity, which are chiefly due to a 
direct action upon the spinal cord, the sensory side of the cord being 
probably more sensitive to the drug than the motor side. Toxic doses 


DELIRIFA Cl ENTS. 


249 


depress and finally paralyze the sensory nerves, and in a much less 
degree the motor nei’ves. The action of the drug upon the circulation 
has not as yet been well made out, but it is probably entirely subordinate 
to its influence upon the nervous system. According to several ob¬ 
servers, the drug is a cardiac stimulant, increasing the power of the 
systolic contractions, and finally arresting the heart in systole; but 
other investigators have found it to produce diastolic arrest, even in the 
isolated heart. Moderate doses cause a rise in the arterial pressure, 
whether by interfering with respiration or by a direct action is at 
present uncertain. Upon striated muscles cocaine appears to have a 
peculiar though very feeble action, which is not manifested during poi¬ 
soning by it. It has been asserted that cocaine acts as a powerful diu¬ 
retic, but the drift of present evidence is to show that it has no definite 
influence upon the amount of urine secreted: what evidence is avail¬ 
able indicates that it decreases elimination of urea. Upon the eye 
cocaine acts as an energetic mydriatic. It is a powerful stimulant to 
the respiratory centres, increasing the rapidity and fulness of the res¬ 
pirations, but if the dose be sufficiently large it after a time causes 
the respirations to become very shallow, and finally paralyzes the respi¬ 
ratory centres. Moderate doses are said to increase, large doses to 
paralyze, peristalsis. 

Local Action. —Locally applied, cocaine acts as a very distinct and 
certain anaesthetic, as was noted by Moreno y Maiz in 1862, and by Yon 
Anrep in 1880, although it was not until September, 1884 ( Wien. Med. 
Wochenschr., Nov. 1884), that Dr. Karl Koller demonstrated the practi¬ 
cal value of the drug. According to the observations of Yon Anrep, 
the nerves of special sense are as readily affected as those of common 
sensibility: thus, cocaine placed upon the tongue abolishes at the place 
of contact, for the time being, the sense of taste. At the point of con¬ 
tact there is at first marked pallor, but after a short time very pro¬ 
nounced redness. In sensitive membranes like the conjunctiva, cocaine 
also causes at first much pain. The primary pallor is alleged to be due 
to a very powerful constriction of the small blood-vessels, and has led 
Dr. F. H. Bosworth to the conclusion that cocaine produces rigid con¬ 
traction in unstriped muscular fibres whenever it comes in contact with 
them ( New York Med. Record , Nov. 15, 1884). 

Therapeutics. —Cocaine appears to act with certainty as a local 
anaesthetic whenever it can reach the nerve-filaments in sufficient con¬ 
centration. The skin will not allow it to pass, while the conjunctival 
and nasal mucous membranes are very permeable, and those of the 
larynx, throat, and vagina are penetrated with more and more difficulty, 
in the order of their naming. Even in disease of the eye, when a deep 
operation is to be performed, such as enucleation, either the alkaloid 
should be injected subcutaneously, or else the solution of the anaesthetic 
must be reapplied at various stages of the operation. To the nasal 
surgeon the alkaloid appears to be invaluable, while the gynecologist 


250 


GENERAL REMEDIES. 


finds it less serviceable, but even he is, by its careful use, able to per¬ 
form many operations without pain. In painful ulcers, fissures of the 
anus, etc., its application will afford temporary relief. It is affirmed by 
various observers that excessive pain is apt to be felt when the anesthetic 
effect is going off, and that this, in many cases, overbalances the first 
relief. It is probable that this pain is the result of the congestion, as 
Dr. Carl Seiler tells me that after nasal cauterizations this after-pain 
can be at once arrested by incising the part slightly so as to cause a 
local bleeding. 

Dr. F. H. Bosworth claims that cocaine is not only extraordinarily 
efficacious as a hemostatic in various surgical cases, but that topically 
applied it will so constringe the blood-vessels of an acutely inflamed 
mucous membrane as to arrest the disease. In bronchitis he applies it 
by means of atomization, using a two-per-cent, solution, and also putting 
the solution freely on the nose and throat. Dr. Bosworth affirms that 
the effects of cocaine upon mucous membranes last for many hours,— 
a statement hard to reconcile with the general testimony as to the 
brevity of the primary bleaching. My own experience is that when¬ 
ever a local inflammation is so situated that cocaine can be properly 
applied to it, immediate relief from pain will be afforded, and that in 
some acute mucous inflammations the effect is permanent. Thus, it is 
often possible to arrest an acute coryza at once by an application of 
a ten-per-cent, cocaine solution to the nostrils. In hay fever, in the pe¬ 
culiar irritated sore throat of advanced phthisis, in chronic laryngitis, in 
inflamed hemorrhoids, even in open ulcerated cancers and other painful 
affections, cocaine as a palliative is invaluable. In boils and carbuncles 
it must be injected directly into the part in order to afford relief. 

The tendency to congestion which follows cocaine-amesthesia cannot 
at present be explained, unless it be due to a relaxation of exhaustion 
following over-stimulation. It is a matter of great practical importance 
in surgery. In 1885 ( Therap . Gaz., Jan. 1885) Dr. P. D. Keyser re¬ 
ported a number of cases of severe inflammation in the eyeballs after 
operations in which cocaine had been used, and I believe oculists have 
now reached the conclusion that cocaine distinctly lessens the resistive 
power of the conjunctiva and cornea, and that after its employment 
active and irritating antiseptic fluids, like solutions of the bichloride of 
mercury, are not always well borne. (For an elaborate discussion of 
the subject, see paper by Adam Frost, Amer. Journ. Med. Sci., April, 
1887.) * 

Drs. E. J. Hall and Halsted (A7. Y. Med. Journ., Dec. 6, 1884) have 
made the very important observation that injecting a solution into a 
nerve-trunk paralyzes sensation over the whole distribution of the 
nerve for about twenty-five minutes. In some cases advantage may be 
taken of this. They used as much as thirty-two minims of a four-per¬ 
cent. solution ; but this produced severe constitutional disturbance, such 
as great giddiness, severe nausea, staggering, cold perspiration, etc. 


DELIRIFA Cl ENTS. 


251 


For local use a four- to ten-per-cent, solution may be employed, and 
when the part is not readily permeable, as in the vagina, it should be 
thoroughly reapplied once or twice at intervals of five minutes. Many 
minor surgical operations can be performed without pain by injecting 
cocaine hypodermically and restraining the circulation by pressure. 
Thus, if a tight band be placed around the proximal end of the finger, 
and cocaine injected, a felon may be opened freely without suffering. 
In a similar way a tumor may be incised from a lip, or a hare-lip oper¬ 
ation performed, if pressure be made around the part by a wire clip. 
Even in the trunk a superficial tumor may often be removed without 
suffering after a concentric series of minute injections of a solution of 
cocaine around its base. 

The stimulant effect of coca upon the cerebrum naturally led to 
the hope that it would be found advantageous in neurasthenia, melan¬ 
cholia, and hysteria, and as a general tonic and stimulant in acute and 
chronic diseases with exhaustion. Clinical experience has not, how¬ 
ever, entirely confirmed this expectation. I have tried it thoroughly 
in a number of cases of melancholia without any benefit whatever, 
and this experience is, I believe, in accord with that of most if not 
all alienists. (See Journ. Mental Science , July, 1887.) Sometimes it 
produces in the beginning of its use a temporary relief, but this effect 
is not pronounced, and almost invariably after a few doses anorexia or 
other disagreeable symptoms demand the withdrawal of the remedy. 
In neurasthenia and hysteria it usually does more harm than good: some¬ 
times, however, the fluid extract added to wine or other alcoholic drink 
seems to exert some stimulant and stomachic influence. In the form 
of large doses of the fluid extract, coca has appeared to me to be of ser¬ 
vice during the breaking off of the opium habit , exerting some stimu¬ 
lant influence upon the nervous system, and restraining the tendency to 
diarrhoea and loss of appetite. Some European clinicians have found 
cocaine of service in the treatment of serous diarrhoeas. It is undoubt¬ 
edly of value for the relief of excessive vomiting , especially when due to 
gastric irritation. Whether it has, as alleged, any very decided powers 
of sustaining men under severe exertion must be considered as yet un¬ 
determined. The muriate of the alkaloid was used by Dr. Aschen- 
braidt in repeated doses of 0.15 grain with great alleged success as a 
stimulant to soldiers making forced marches ( Deutsch. Med. Wochenschr ., 
1883, ix. 50). 

The best preparation of coca for internal use is the fluid extract, the 
dose of which is one-half to two fluidrachms. The dose of cocaine is 
one-fourth to one grain. 

Toxicology.— Two fatal cases of poisoning by cocaine are said to 
have occurred in Russia, but I have seen no detailed account of them. 
Five grains taken by the mouth by mistake caused nausea, loss of sight, 
incoherence of speech, severe sweating, rapid intermittent pulse, cyano¬ 
sis, and suffocation ( Pharm. Journ. Trans., xvii. 507). In a similar case 


252 


GENERAL REMEDIES. 


Dr. E. Caudwell (Brit. Med. Journ ., i., 1885) noted excessive giddiness, 
supraorbital headache, widely-dilated pupils, partial loss of sight, and 
a fall of bodily temperature to 96.7° F. The hypodermic injection 
of five grains was followed in fifteen minutes by general convulsions, 
loss of consciousness, unequal dilatation of the pupils, evidences of 
asphyxia, with labored respiration, feeble pulse, and pale and purplish 
surface. In another case the injection of about two grains and a half 
produced in a man an epileptic attack (Dr. S. T. Earle, Maryland Med. 
Journ ., vol. xvi. p. 396). A man took ten grains hypodermically, in the 
course of five hours, during a spree: two hours later the face was ashy 
pale, the hands quite blue, the eyelids tightly closed, the pupils con¬ 
tracted, the pulse feeble and fluttering, respiration slow, unconscious¬ 
ness complete: under appropriate treatment, in about one and a half 
hours signs of returning consciousness were manifest, and recovery 
occurred (J. S. Spear, N. Y. Med. Rec., Nov. 14, 1885). According to 
Yon Ploss (quoted by Husemann, Die Pflanzenstoffe, 2d ed.), an apothe¬ 
cary took for suicidal purposes twenty-two grains of cocaine in a glass 
of beer. He shortly afterwards went to sleep, but awoke in some 
hours with great abdominal pains, dryness in the mouth, excessive wake¬ 
fulness, and vertigo, and suffered from suppression of urine for twenty- 
four hours, but had no further disturbance of consciousness or of the 
heart’s action. 

The local application of cocaine is said to have produced various 
constitutional symptoms. Thus, two drops of a two-per-cent, solution 
repeatedly applied to the cornea caused nausea and vomiting, lasting 
for many houi’S, with great prostration and paralysis of the tongue 
and limbs (Mayerhausen, Centralbl. f. d. Gesammt. Ther ., Oct. 1885). 
An application of a four-per-cent, solutioix to the nasal mucous mem¬ 
brane was followed by marked syncopal symptoms (Dr. Ziem, Brit. 
Med. Journ ., Nov. 21, 1885). An application to the laiynx pi’oduced in a 
boy mai’ked weakness and other evidences of intoxication, lasting for 
ten hours (Heymann, Deutsch. Med. Wochenschr., No. 46, 1885; see also 
T. S. Williams, N. Y. Med. Rec ., vol. ii., 1886). It is a matter of some 
doubt how far the symptoms in these cases have been psychical, and 
how far directly caused by the di’ug; but the evidence is sufficient 
to show that excessive susceptibility to the influence of the alkaloid 
may exist as an idiosyncrasy. In some cases extraordinarily severe 
symptoms are alleged to have been induced by the internal use of small 
amounts of the drug. Thus, four minims of a twenty-pei’-cent. solu¬ 
tion given hypodermically are said by Dr. Ramsden Wood (Australasian 
Med. Gaz ., Aug. 1886) to have caused great rigidity, convulsive respi¬ 
rations, and collapse. 


FAMILY V.-EXCITO-MOTORS. 


In this class are included such drugs as increase the reflex activity 
of the spinal centres and thereby give rise to disturbance of motility. 
The only representatives of the class used by the practitioner of medi¬ 
cine are those drugs which contain strychnine as their active principle. 

NUX VOMICA-NUX VOMICA. U.S. 

The seeds of Strychnos Xux-vomica, a middle-sized tree growing in 
the East Indies, whence the drug enters commerce. They are circular, 
nearly flat disks, a little less than an inch in diameter, covered with 
very short, satin-like, grayish hairs; internally they are tough and 
horny, and are possessed of an intensely bitter taste. They contain 
two alkaloids,—strychnine and brucine,—existing in combination with 
an acid, the igasuric of Pelletier and Caventou, which, according to 
Husemann, is probably identical with malic acid. Brucine , which, 
unlike strychnine, is liot officinal, is readily recognized by the following 
test. When concentrated nitric acid is added to it, a beautiful scarlet 
or blood-red color is developed, which becomes yellowish-red, and, by 
warming, yellow; if to this yellow solution, somewhat diluted, some 
chloride of tin or sulphuret of ammonium be added, it will become a 
beautiful reddish-violet. Physiologically and therapeutically this alka¬ 
loid is similar to, but weaker than, strychnine. 

The dose of the extract (Extractum Nucis Vomicce, U.S.) is from one- 
fourth to one half of a grain, given in pill; of the tincture ( Tinctura Nucis 
Vomicce —1 to 5, U.S.), usually fifteen to twenty-five drops, but, as five 
minims represent the two-hundredth of a grain of strychnine, it may 
be administered in much larger amounts; of the abstract (Abstractum 
Nucis Vomicce , U.S.), one to two grains; of the fluid extract (Extractum 
Nucis Vomicce Fluidum, U.S.), two to three minims. 

STRYCHNINA. U.S. 

As kept in the shops, strychnine is a grayish-white powder, but by 
slow crystallization from its alcoholic solution it may be obtained in 
octahedral or quadrilateral prisms. It is soluble in about seven thou¬ 
sand parts of cold water; in two thousand parts of boiling water; 
very sparingly soluble in absolute alcohol, ether, and benzin; freely 
soluble in boiling officinal alcohol, which deposits it on cooling. It is 

253 



254 


GENERAL REMEDIES. 


so bitter that it will impart a very intense taste to twenty thousand 
times its weight of water. 

Strychnine yields a very pronounced violet color with many oxi¬ 
dizing agents. The one most ordinarily employed is a mixture of con¬ 
centrated sulphuric acid and bichromate of potassium (Otto's test). 
According to Dr. Guy, the test is most delicate if the alkaloid be 
dissolved in a little concentrated sulphuric acid on a plate, and the 
bichromate added to it, when a bluish and then violet-purplish color is 
developed, passing finally into a dirty green. Davy's test consists in 
the substitution of a crystal of red prussiate of potassium for the 
bichromate. Marchand uses the peroxide of lead; in this case the 
sulphuric acid should contain one per cent, of nitric acid. Drs. Yrij 
and Yan der Burg say that these tests are about equally sensitive, and 
are capable of revealing the one-sixty-thousandth of a grain of the 
alkaloid. Either the chlorate or the permanganate of potassium may 
be used instead of the bichromate; indeed, Dr. Guy claims that the 
permanganate is preferable to the latter. If the strychnine be in 
quantity, it may be dissolved in very dilute sulphuric acid, and solu¬ 
tion of bichromate of potassium be added, when golden-red needle-like 
crystals of the chromate of strychnine will separate. These dissolve, 
with the production of a beautiful blue color, in concentrated sulphuric 
acid. F. L. Sonnenschein ( Vierteljahresschrift fur Prakt. Pharmacie , 
1871) says that if strychnine be dissolved in a strong solution of the 
sulphate of sesquioxide of cerium a beautiful color is induced, which 
generally passes into a cherry-red, and so persists for several days. 
Dr. Filchol’s test ( Lancet , April, 1872) consists in the addition of solu¬ 
tion of chloride of gold, and the testing of the precipitate by Otto’s 
method. The 'physiological test for strychnine is a very sensitive one. 
In it a fragment of the suspected extract, dissolved in a little acidulated 
water, is thrown into the cellular tissue of a small frog, which should 
afterwards be allowed to swim about freely, so that its unconstrained 
movements can be watched. 

Physiological Action.— Strychnine acts in the same way upon 
almost all animals. According to Leube ( Reichert's Archiv fur Anat., 
1867, p. 630), however, it takes ten times as much to kill chickens as it 
does to kill other birds, weight for weight; and among mammals the 
guinea-pig is very insensitive to it. It has also recently been asserted 
that on some monkeys it has very little influence ( Boston Med. and 
Surg. Journ., 1872). Its local action is that of a slight irritant.* 

When taken in quantities just sufficient to produce sensible physio- 


* For an elaborate memoir on the effect of age on the action of strychnine, see Arch./. Gee. 
Physiol., 1884, xxiv. 530. It is affirmed that very young animals require very large doses 
to kill. This is confirmed by Behrend Lau (Elmshorn, Inaug. Biss., 1886), and is in acoord 
with the observations made in the out-patient department of the Hospital of the University 
of Pennsylvania by Dr. J. II. Musser, who finds that age very greatly increases the suscepti¬ 
bility to nux vomica. 



EXCITO-MOTORS. 


255 


logical effects, strychnine in man induces a feeling of restlessness, per¬ 
haps accompanied by tremblings in the limbs and some stiffness in the 
neck and jaws. When a somewhat larger amount has been given, there 
may be general muscular twitchings and startings, with stiffness and 
stricture of the throat and chest; formications or other abnormal sen¬ 
sations under the skin may or may not be present. After poisonous 
doses the symptoms come on usually in from fifteen to twenty minutes, 
rarely after the hour, with great suddenness; sometimes the convul¬ 
sions are preceded by partial spasms of the muscles of the extremities, 
but more often the patient is suddenly thrown down by a general te¬ 
tanic spasm. In this the body is bent backwards and rests upon the 
heels and the head, in a condition of profound opisthotonos ; the legs 
are rigidly extended and the feet everted ; the arms bent and the hands 
clinched; the eyes staring, wide open; the corners of the mouth often 
drawn up so as to produce the risus sardonicus. The senses are often 
sharpened, but ringing in the ears and dimness of vision may be in¬ 
duced if the fits are severe. The face is at first pale, but, if the fit 
be sufficiently severe and protracted, it becomes livid from the inter¬ 
ference with respiration. Consciousness is not affected, unless when 
asphyxia becomes so pronounced as to threaten death; in such cases 
sometimes a period of insensibility precedes dissolution, but generally 
the intellect is clear to the moment of death. The muscles of the jaw 
are usually the last in the body to be affected, but trismus finally comes 
on in severe cases. I have seen death occur in this first convulsion in 
animals; but Tardieu states that he knows of no such instance in man 
(compare case of Dr. Demme, Syd. Soc. Year-Book , 1865-66, p. 441). 
After a time the paroxysm is at an end, the jaw drops, the muscles 
relax, and a period of calm comes on, to be succeeded by a second con¬ 
vulsion like the first. These convulsions are excited by the slightest 
touch, by a draught or breath of air, even by a loud sound; but a firm 
grasp or hard rubbing of the muscles is frequently grateful. A slight 
rigidity is sometimes manifest between the paroxysms, but no marked 
stiffness. The spasms are generally, but not always, very painful. 
There are often erections of the penis, and the fteces and urine may be 
passed involuntarily. If the case terminates favorably, the convulsions 
gradually lessen in intensity, and fade away, leaving the patient ex¬ 
hausted, with a sore, tired feeling in the muscles. After death, post¬ 
mortem rigidity is developed very quickly. Autopsies have revealed 
nothing but the usual congestive lesions of death from asphyxia, and, 
at times, indications of spinal hypersemia. 

In regard to the method in which strychnine produces the above 
symptoms, it is obvious that the alkaloid is primarily absorbed; and 
experimental proof seems so superfluous that I will only mention the 
fact that Masing has found the strychnine in the blood. 

It is very plain that convulsions can be produced by a drug in only 
five ways : first, they may be epileptiform,— i.e., cerebral; second, they 


256 


GENERAL REMEDIES. 


may conceivably be due to a stimulation of the peripheral ends of the 
motor nerves; third, they may conceivably be caused by irritation of the 
peripheral ends of the sensory nerves; fourth, they may be muscular, 
— i.e., due to a direct action on the muscles; fifth, they may be spinal. 

That the convulsions of strychnine-poisoning are not cerebral, is 
proved by the fact which has been frequently noted, and which I have 
confirmed, that they are not affected by section of the cord, or, at least, 
are only so far affected as to be more severe in those portions of the 
body removed from the cerebral influence. That they are not due to 
irritation of the peripheral motor nerves and are not muscular is proved 
by the experiment of Valentin ( Pathologie der Nerven, p. 327, Leipsic, 
1864), who found that the injection of a solution of strychnine through 
the blood-vessels of the amputated leg of a frog had no influence upon 
the muscles. A very beautiful experiment of Brown-Sequard ( Comptes- 
Jtendus, 1849) confirms this, and also demonstrates that the convulsions 
do not arise from hyper-excitability of the peripheral afferent nerves. 
The observer last mentioned found that when the spinal cord was cut 
just below the origin of the nerves supplying the fore legs of a frog, 
and all the blood-vessels going to the lower section of the cord were 
also severed so as to isolate the latter, on the exhibition of strychnine 
convulsions occurred in the anterior part of the body, while in the pos¬ 
terior segment quiet and a normal reflex activity were maintained, 
although the blood was carrying the poison to every part of it except 
the spinal cord. The philosophy of this is evident. The anterior sec¬ 
tion of the cord, receiving the poison, gave rise to convulsions; the pos¬ 
terior section, receiving no poison, maintained its usual status. 

This experiment of Brown-Sequard has been repeated a great num¬ 
ber of times by MM. Martin-Magron and Buisson (Journ. de la Physiol., 
1860, t. iii. p. 130) with similar results, excepting that in some very 
rare instances slight convulsions were induced in the posterior portion 
of the body. These exceptional phenomena appear to have been due 
simply to a minute portion of the poison reaching the spine by imbibi¬ 
tion, since, when by an operative procedure not necessary here to 
detail (loc. cit., p. 131) the posterior section of the cord was completely 
isolated and access of the poison by diffusion rendered impossible, 
spasms never occurred in the posterior part of the body. 

Strychnic convulsions must be spinal, because they do not arise in 
any of the other possible methods. This conclusion is abundantly con¬ 
firmed by direct experiment. Thus, Van Deen ( Physiol. de la Moelle 
epiniere) and Valentin (loc. cit., p. 329) have shown that when the alka¬ 
loid is placed upon the spinal cord, and allowed slowly to diffuse itself, 
the usual convulsions occur, but are at first confined to those muscles 
whose nerves have their origin near the point of application, and after¬ 
wards spread from muscle to muscle as the poison creeps through the 
cord. Dr. A. J. Spence ( Edinburgh Med. Journ., July, 1866) lias per¬ 
formed similar experiments, with similar results. He first bisected the 


EXCI TO-MO TORS. 


257 


apex of a frog’s heart so as to allow all the blood to drain from the 
body, and then, cutting through the cranium, laid a little piece of nux 
vomica upon the brain so that the poison would diffuse down through 
the spinal cord. The result was that first the muscles of the throat, 
then those of the fore legs, and so on in regular order, were affected.* 
Spinal Cord. —Claude Bernard ( Legons sur les Substances toxiques , 
Paris) has denied that strychnine produces excitation of the spinal 
motor centres, because when all the posterior nerve-roots are cut, no 
convulsions occur, whereas if a single afferent root be allowed to 
remain, irritation of its peripheral fibrillse will cause general tetanic 
spasms. Allowing the truth of his experimental fact, his deduction 
certainly is not warrantable.f The non-occurrence of convulsions may 
depend upon the fact that the reflex motor ganglionic cells are incapa¬ 
ble of originating an impulse, and in strychnine-poisoning are simply 
in such a condition of over-excitability as renders them exceedingly 
sensitive to slight irritations and causes them to respond most ener¬ 
getically to peripheral impulses so feeble as not to be felt in health. 
That the motor centres are acted upon by strychnine is proved not 
only by the experiments that have been already detailed, but also by 
the following ingenious one of Van Deen ( Physiol. de la Moelle epiniere). 
This investigator removed the viscera, vessels, etc., from a frog, so as to 
leave nothing below the second cervical vertebra but the bones, nerves, 
and muscles; then, opening the spinal cord in the region of the third 
vertebra, he cut entirely through the anterior columns of the cord, 
and finally divided all the tissues, so that the anterior portion of the 
frog was connected with the posterior solely by the posterior columns 
of the cord. When one or two drops of a solution of strychnine were 
placed in the mouth of the prepared batraehian, tetanus, confined to 
the anterior segment of the body, was developed; and it was also 
found that while irritation of the posterior feet caused in them only 
ordinary reflex movements, in the front legs tetanic spasms were simul¬ 
taneously induced. It appears to me proved by the evidence adduced 
in this and the preceding paragraphs that strychnine is a powerful 
stimulant to the cells of the spinal cord ; including in this term the 
whole spinal tract up to the pons Varolii. As shown by Spitzka, and 
confirmed in my laboratory, enormous doses of strychnine injected into 


* Some of the phenomena stated by Dr. Spence to have occurred are at present very diffi¬ 
cult to explain. Thus, he noted that as the poison travelled down the cord there was a time 
when irritation of the fore feet caused only spasm in them; later in the experiment, irritation 
of the front feet caused spasm of both the front and hind feet, although irritation of the latter 
did not produce other than normal reflex movements; later still in the poisoning came a stage 
when irritation of the front legs was powerless to cause spasm in the hind legs, although irri¬ 
tation of the latter would now cause spasm in the former. 

f Dr. Spitzka (Chicago Journ. Ment. and Nerv. Dis., vi. 216) affirms that a frog with all 
the sensory nerve-roots and the nerves of special sense divided still develops tetanus when 
strychnine is administered. It would be strange if so noted a physiologist as Claude Bernard 
should make so gross an error in experimentation. 

17 



258 


GENERAL REMEDIES. 


a vein kill almost instantaneously without the production of a spasm. 
Such doses probably kill the nerve-centres, just as large doses of a car¬ 
diac stimulant overwhelm and paralyze the viscus. 

Motor Nerves. —The action of strychnine upon the motor nerves 
has been a subject of considerable controversy. That the convulsions 
occur independently of any such influence, if it exists, has been already 
shown. After death from strychnine, the functions of the motor 
nerves are always found to be more or less impaired, so that galvaniza¬ 
tion of the nerve-trunk produces either only very feeble contractions 
in the tributary muscles, or else none at all* Of this fact there would 
seem to be no doubt; it has been attested on the evidence of personal 
experiment by many observers, among whom are Matteucci ( Traite des 
Phenomenes electro-physiologiques , Paris, 1844), Moreau ( Comptes-Pendus 
Soc. de Biol., 1855), M. Ambrosoli ( Gazette Medicate, 1857, p. 525), "VYit- 
tich ( Bericlit d. Fortschritte d. Anat., 1857, p. 434), Ivolliker ( Virchow's 
Archiv, Bd. x. p. 239, 1856), and Yulpian ( Archives de Physiologie, Nov. 
1870, p. 125). Now, it is evident that this absence of response may 
be due to loss of functional power in either muscle or nerve. Some¬ 
times the muscle may be at fault; but, as Matteucci {loc. cit.) insists, 
and as has been noted by many observers, not rarely—indeed, most 
generally—in the frog galvanization of the nerve fails to elicit response, 
although the muscle preserves its irritability. M. Ch. Eichet ^Comptes- 
Pendus, xci. 131) determined experimentally that if active artificial 
respiration be maintained, enormous doses of strychnine injected into 
the vein of a mammal paralyze the motor nerves. M. Yulpian {Ibid., 
xeiv. 556) has confirmed these results: so that it may be considered 
proved that in the warm- as well as in the cold-blooded animal strych¬ 
nine depresses directly the motor nerves. 

It having been proved that the functional power of the motor nerves 
is destroyed in strychnine-poisoning, the question arises, Is this de¬ 
struction a direct action of the poison, or is it simply the exhaustion 
of over-use, due to the intense activity of the nerve during the stage 
of spasm ? 


* Dr. W. H. Klapp affirms that he has found in thirty-seven experiments the motor nerve 
unimpaired in the frog after death from strychnine ( Journ. Merit, and Nerv. Dis., Oct. 1878). 
It is inconceivable that all previous observers should be mistaken in their observations. It has 
been suggested that the effects upon the motor nerves usually attributed to strychnine have 
been due to brucine contaminating it; and Dr. Robert P. Robins ( Phila. Med. Times, ix. 228) 
has found nerves insensitive in animals killed with brucine,—a result in accord with the 
experiments made upon Rana esculenta by Professor Mounier, of Geneva. Dr. Lautenbach 
has shown, however, that chemically pure strychnine impairs the function of the motor nerves, 
and that in some frogs, or under some life-conditions, brucine has no effect upon the nerves. 
It would seem that both of these alkaloids impair the functions of the motor nerves, but that 
under certain conditions the nerves have greater resisting powers than usual. It is probably 
different states of health rather than different species of frogs, as believed by Lautenbach, 
that cause the diversity of results. The possibility of a stray galvanic current being directly 
transmitted by a nerve to a muscle must also not be forgotten. 



EXCITO-MOTORS. 


259 


It cannot be gainsaid that the power of the nerve is lessened by 
the strain upon it during the convulsions; and Ivolliker concludes ( Vir¬ 
chow's Archiv, Bd. x., 1856) that this is the sole cause of the nerve- 
paralysis, because when he cut the sciatic nerve of a frog and exhibited 
strychnine the divided nerve would respond to galvanic stimuli after all 
functional power had been lost in the nerve whose connection with the 
centres was intact. Granting the experimental fact, it would only prove 
that contact of the poison was not the sole cause of the motor-nerve 
paralysis, as it is plain that although both nerves suffered this contact, 
yet the uninjured one suffered it plus exhaustion from excessive use. 
The conclusion is, moreover, opposed by the fact attested by Yulpian 
(.Archives de Physiologie , 1870, t. iii. p. 120) and other observers, that an 
enormous dose of strychnine kills the frog without the induction of 
spasms by general paralysis, with total loss of power in the nerve- 
trunks. Evidently in such case the action of the poison on the nerves 
must be direct. 

MM. Martin-Magron and Buisson have investigated (Journ. de la Phy¬ 
siol ., 1860, t. iii. p. 342) very elaborately this action of strychnine upon 
the nerves, and the correctness of their experiments and results seems 
to me scarcely questionable. They found (loc. cit., p. 347) that if the 
sciatic nerve of a frog were cut and a sufficiently large dose of the 
strychnine administered, the divided sciatic lost its irritability, although, 
unless the dose was very large, not so soon as did its fellow. Yulpian 
(loc. cit., p. 126) has confirmed this; and the opposite result of Kolliker 
no doubt depended upon his not using sufficiently large doses of the 
alkaloid or upon his testing the nerve too early. Martin-Magron and 
Buisson also tied all the tissues of a frog’s leg except the nerve, and 
then, on exhibiting strychnine, found that convulsions ceased in the 
poisoned much sooner than in the non-poisoned leg, and that at a certain 
time irritations of the poisoned foot would induce tetanic spasms only 
in the non-poisoned member ,—proof that the afferent nerve-fibres of the 
poisoned leg were not affected, and that the motor nerves were paralyzed 
wherever the poison had access to them, and that to this, not to spinal 
exhaustion, was due the general paralysis. 

M. Yulpian (loc. cit., p. 121) affirms that he has repeated this experi¬ 
ment many times, and always obtained the same result as Martin- 
Magron and Buisson. It would seem to prove that strychnine in very 
large doses paralyzes the efferent but not the afferent nerves, and that 
the collapse of strychnine-poisoning in the frog is largely due to the 
affection of the motor trunks, and not to exhaustion of the spinal cord. 
Again, Yulpian (loc. cit., p. 122) found that the nerve protected by tying 
its vessels preserved its irritability after the non-protected nerve had 
lost its functional power. The evidence appears to be as complete as it 
can be, and to show that in strychnine-poisoning, at least in the frog, the 
motor nerves lose their functional power partly through exhaustion and 
partly through a direct action of the poison upon them. That which 


260 


GENERAL REMEDIES. 


Fraser has discovered for atropine, Vulpian (loc. cit., p. 128) has found 
for strychnine: namely, that after a time,—say from some hours to two 
days,—if the dose has been of the right size, the strychnic paral}*sis 
passes off, the motor nerves are found to have regained their power, 
and the convulsions reappear, to continue hours or days. 

Circulation .—Strychnine has a very decided influence upon the 
circulation. Drs. Richter (Zeitschrift f. ration. Med., 1863, xviii.), Mayer 
(Med. Jahrb. d. k. k. Gesellschaft der Aerzte zu Wien , 1872, p. 112), Schle- 
singer (Ibid., 1874), and Klapp (Journ. Ment. Dis., Oct. 1878) have all 
found that a decided rise of arterial pressure comes on before or about 
the time of the first convulsion. The rise is not due to the convulsion 
or to the interruption of the circulation, as it occurs in curarized ani¬ 
mals in which artificial respiration is maintained.* Both Richter and 
Mayer affirm that the small arteries can be seen to contract under the 
influence of the strychnine, and conclude that the rise of the pressure 
is due to vaso-motor spasm. Mayer also noted that after paralysis of 
the dominant vaso-motor centres by section of the cord, strychnine 
produced no rise of the arterial pressure, or if any was caused it was 
very slight. A different experimental result has, however, been reached 
by Schlesinger (loc. cit.). This investigator found that the rise after 
the division of the cord both absolutely and relatively exceeds that pro¬ 
duced in the normal animal. It is worthy of note that in three of the 
fifty experiments made by Schlesinger upon rabbits the strychnine 
failed to elevate the pressure after section upon the cord. Schlesinger 
explains the apparently opposite results reached by himself and by 
Mayer by the fact that the latter investigator employed dogs, and fur¬ 
ther states that in six experiments made by himself on dogs he four 
times obtained results similar to those of Mayer. Klapp experimented 
upon the cat, dividing not only the spinal cord, hut also all the cardiac 
nerves of the neck. Under these circumstances no rise of pressure 
followed the injection of the strychnine. I have no doubt that the ex¬ 
planation given by Klapp of the peculiar results obtained by Schlesin¬ 
ger, namely, that it was because he failed to make a perfect section 
of the cord, is correct. Schlesinger also found that in the strychnized 
animal stimulation of a sensitive nerve produced rise of pressure by 
vaso-motor spasm even after section of the spinal cord. The explana¬ 
tion that he offers of this is that in the normal animal the peripheral 
impulse can only reach the vaso-motor nerves by first going to the 
dominant centres in the medulla, but that strychnine so alters the func¬ 
tional conditions of the spinal cord as to allow the peripheral impulses 


* In the experiments of J. Denys (Archiv f. Exper. Path. Pharm., Bd. xx. S. 306) the 
rise of the blood-pressure was found to be much more pronounced after small doses of strych¬ 
nine in curarized animals than in the normal animal. In the normal animal after spasms 
there was a very pronounced fall in the arterial pressure. It is probable, therefore, that 
during convulsion the vaso-motor centre shares in the general nervous discharge, and that 
the circulation partakes in the relaxation and exhaustion which follow a tetanic lit. 



EXCITO-MO TORS. 


261 


to bring a response by acting upon the local vaso-motor centres in 
the cord,—that is, by causing a general vaso-motor spasm. The cor¬ 
rect interpretation of this alleged discovery of Schlesinger is probably 
that he obtained a rise of pressure because he had failed entirely to 
sever the spinal cord. It must, however, be acknowledged that al¬ 
though in the majority of Klapp’s experiments no rise of pressure 
occurred in the strychnized animal after section of the spinal cord 
upon galvanization to a sensitive nerve, in a few instances such rise 
did happen, probably because a few fibres of the spinal cord were left 
uncut. 

It has been shown by the experiments of Klapp that the primary 
stimulation of the vaso-motor centres by strychnine is followed by fall 
of arterial pressure and vaso-motor palsy; also that very large doses 
produce an immediate depression of the vaso-motor centres and fall of 
arterial pressure. 

There is some apparent conflict of testimony in regard to the in¬ 
fluence of strychnine upon the inhibitory cardiac nervous system. 
Dr. Carl Heinemann, who has investigated at some length ( Virchow's 
Archiv, Bd. xxxiii. p. 394) the influence of the drug upon the heart of 
the frog, finds that large doses cause diminished frequency of the car¬ 
diac movements, with diastolic pauses.* According to his experiments, 
these phenomena are not due to stimulation of the inhibitory nerves, 
since they occur after section of the vagi (p. 403), nor are the peripheral 
vagi paralyzed, since galvanization of one of these nerves causes imme¬ 
diate diastolic cardiac arrest (p. 406). Mayer (Joe. cit .) has also found that 
the peripheral vagus is not paralyzed, since he could suspend the action 
of the heart in the poisoned animal by galvanization of the par vagum. 
Klapp has also reached results confirmatory of those of Heinemann. 
On the other hand, Martin-Magron and Buisson affirm Joe. cit., p. 352) 
that in all of very many experiments, after a greater or less length of 
time, the pneumogastrics lost their power of transmitting an impulse. 
The reconciliation of these results is very difficult: possibly Martin- 
Magron and Buisson employed a strychnine containing very largely 
of brucine ; possibly enormous doses of strychnine do affect the periph¬ 
eral vagi, but not until very late in the poisoning, although, when small 
doses are employed, even death may occur without very decided paral¬ 
ysis of these nerves. That the different results are not due to the 
use of different animals is evident, since, although Mayer used hounds, 
both Heinemann and Klapp employed the same animals as did Martin- 
Magron and Buisson,—viz., frogs. Dr. I. Steiner has found the action 
of strychnine much more marked when it is placed upon the posterior 


* For the paper of Brunton and Cash showing that strychnine increases the “refractory 
period” of the isolated frog’s heart, see Proc. Roy. Soc., 1883. A consideration of this 
memoir would require an elaborate discussion of the minute points of cardiac physiology, 
and, as it would throw at present no light upon the practical use of the drug, is not entered 
upon. 



262 


GENERAL REMEDIES. 


than when it is placed upon the anterior face of the frog’s heart, also 
that the strychnine acted much more promptly and severely upon the 
separated sinus venosus than upon the ventricles or the auricles, and 
hence concludes that the strychnine acts especially upon the ganglia 
of the sinus. Ilis experiments and conclusions have been confirmed 
by Klapp, and are probably correct. 

Upon the blood strychnine has probably some action. Harley found 
that blood shaken for twenty-four hours with air contained 11.33 parts 
of oxygen and 5.96 parts of carbonic acid; while blood treated in a 
precisely similar manner, except in the addition of strychnine, yielded 
17.80 parts of oxygen and 2.73 parts of cai’bonic acid. He concludes 
from this that strychnine arrests oxidation in the body; but the deduc¬ 
tion seems to me out of all proportion to the fact. 

Eye. —The effect of strychnine upon the normal eye has been 
recently studied by V. Hippel ( Wirkung des Strychnins auf die normale 
und kranke Augen, Berlin, 1873) and Cohn ( Wiener Mediz. Wochenschrift, 
Nos. 42, 47, 1873), with rather different results. They both, however, 
found the sharpness of vision increased.* 

Elimination. —Strychnine is eliminated with the urine, according to 
the experiments of Peter von Kaut'enfeld, unchanged and very slowly 
( Inaug. Dissert., Dorpat, 1884). P. C. Plugge has found, however, that 
at least a portion of the strychnine is oxidized and converted into a 
new substance, which he calls strychnic acid. (For details, see Archiv 
der Pharmacie, 1883, p. 652.) 

Therapeutics. —As a vegetable bitter, strychnine is a stomachic, 
stimulating to a greater or less degree the digestion, besides acting 
more universally on nerve-power. It is more than a mere stomachic: 
clinical experience has shown that it is a most useful tonic when there 
is general relaxation and loss of nerve-power. A portion of its value 
arises, it may be, from its action upon the spinal motor nerve-centres; 
but in all likelihood it influences other portions of the cord, affecting 
the vaso-motor centres, and most probably also the trophic centres. Be 
these things as they may, clinical experience has abundantly demon¬ 
strated the value of the drug as a tonic in general functional atony and 
relaxation. 

The great influence of strychnine upon the function of voluntary 
motion early led to its use in cases of paralysis, often with the result of 
doing harm rather than good. Its peculiar physiological action being 
known, it becomes very evident that it can be useful only when the 
paralysis is dependent upon, or at least accompanied by, a depressed 
state of the spinal or other motor centres. Whenever there is inflamma¬ 
tion or irritation of these latter, strychnine may do great injury by in¬ 
creasing such irritation, and must never be employed. Like galvanism, 


* For the details of their studies the reader is referred to the original paper, or to the 
abstract in the Boston Med. and Surg. Journ., p. 473, 1874. 



EXCITO-MOTORS. 


263 


in hemiplegia it can do only a very limited amount of good, and should 
not be exhibited until irritation from the clot has ceased. It is probably 
useful in all forms of lead paralysis , but when the symptoms resemble 
those of poliomyelitis— i.e a multiple paralysis with rapid wasting 
of the affected muscles and alterations of the electro-contractility—I 
have found strychnine pushed to the verge of poisoning extraordinarily 
efficacious. 

Since attention was so signally called to the value of strychnine in 
amaurotic affections by Nagel, of Tubingen, in 1871, numerous observers 
have published extended series of cases in which it has been used with 
strangely-varying results. They have for the most part, however, 
served to verify the favorable results obtained by Nagel ( Die Behand- 
lung der Amaurosen und Amblyopeen mit Strychnin , Tubingen, 1871). His 
sanguine expectations regarding its use in nerve-atrophy have met with 
disappointment in the hands of other observers. It is now conceded that 
in atrophy of the essential nerve-structure little is to be expected from 
strychnine or any other means. It is most useful in cases which have 
not yet reached the stage of atrophy, but present slight if any ophthal¬ 
moscopic changes. The chalky or greenish-white and cupped nerve- 
entrance is not always, however, sufficient cause for pronouncing the 
case hopeless, for these appearances are not always safe indications of 
the amount of injury done to the axis-cylinders. Its value in amaurosis 
from abuse of alcohol and of tobacco is undisputed. Also in amblyopia 
from disuse,— e.g.> in strabismus and paresis,—after the parallelism of 
the visual axes has been restored, under its use normal sharpness of 
vision is much more rapidly attained. In cases where the ophthalmo¬ 
scope reveals but slight change in the retina and nerve,— e.g ., slight 
striation of retina around the disk, the margin of which is somewhat 
obscured, or in disturbances of the anastomotic circulation at the 
nerve-entrance, with or without diminished sharpness of central vision 
and contraction of the field,—strychnine is of marked benefit. The dis¬ 
tressing headache and giddiness associated with these nerve-troubles 
which thus manifest themselves in the eye are frequently relieved by 
the use of strychnine, even though the nerve is quite atrophied and the 
eye blind. There is much difference of opinion as to the method of its 
administration, but better results in the hands of most observers follow 
its hypodermic use. The temple would seem to be a better locality 
than the arm, as improvement in the corresponding eye has been fre¬ 
quently observed, while its fellow remained as before. It should he 
given in gradually-increasing doses, being governed by the tolerance 
of the action of the drug. Commencing with one-thirtieth of a grain, 
it can usually in a few weeks be carried up to one-tenth or even one- 
fifth of a grain once or twice daily, these doses causing only a twitch¬ 
ing in the calves of the legs, or a slight sense of constriction about the 
throat, coming on in from ten to fifteen minutes after their adminis¬ 
tration, and subsiding in the course of an hour or two. It is necessary 


264 


GENERAL REMEDIES. 


to maintain the physiological impression of the drug to insure the best 
results.* 

Dr. J. Milner Fothergill not long since called attention to the value 
of strychnine as a respiratory stimulant in dyspnoea dependent upon 
pulmonic affections, such as chronic bronchitis, emphysema, and phthisis. 
In long-standing bronchitis , or “ winter-cough ,” with a dilated right heart, 
the combination of strychnine and digitalis in his hands has acted ex¬ 
ceedingly well. In other cases he is accustomed to add the strychnine 
to ordinary stimulant cough mixtures. This practice of Dr. Fothergill 
has found many imitators, and the value of strychnine as a respiratory 
stimulant is well established. 

In dyspepsia or constipation or diarrhoea, connected with atony of 
the visceral muscular coat, strychnine is a very valuable remedy. In 
various local paralyses, such as prolapse of the rectum, atonic retention of 
urine, atonic incontinence , and loss of voluntary motion in certain groups 
of muscles from temporary injury to the supplying nerve or even from 
so deep-seated a disease as infantile paralysis , it is useful. There is 
reason to believe that it sometimes does good in these cases by influ¬ 
encing the nutrition of the affected muscle or the peripheral nerves; 
and it should be injected into the affected part. 

Strychnine is also a serviceable remedy as a stimulant in cases of 
mental and physical depression due to prolonged excitement and over¬ 
work. Dr. J. II. Musser ( Therap. Gaz., ii. 10) asserts that during the 
strain of student-life before examination it is especially valuable in 
preventing the development of asthenopia. 

Toxicology.— Sufficient has already been said in regard to the gen¬ 
eral symptoms of strychnine-poisoning. It only remains to discuss the 
diagnosis. - } - This is especially important, because strychnine is frequently 
used criminally, and because not rarely it is impossible for the chemist 
to detect it after death. The only disease with which jioisoning by it 
may be readily confounded is tetanus, in its various forms of idiopathic, 
rheumatic, traumatic, infantile, and hysterical. It has been asserted 
that in fatal cases the duration of the attack will always distinguish 
between natural tetanus and that produced by poison. Dr. Louis 
Starr, however ( Pliila. Med. Times , iii. 311), reports a Case of traumatic 
tetanus fatal in less than twelve hours after the first appearance of mus¬ 
cular twitchings, and within one hour and a half after the first convul¬ 
sion ; and according to Jaccoud, death has occurred fifteen minutes after 
the reception of the injury ( Pathologie Interne , i. 441). 

The following table shows, I think, in as clear and brief a manner 
as possible the differences between traumatic or idiopathic tetanus 


* This paragraph was written by Dr. S. D. Risley, and is expressive of the results at the 
University Hospital, where he is chief assistant of the Ophthalmological Clinic. 

f A lesion found in one case by Moriz Rosenthal may possibly be characteristic. It is 
numerous small cross-rents in the heart-muscle, accompanied by small extravasations ( Nerven - 
krankheiten, 1870, p. 334). 



EXCITO-MO TORS. 


265 


(No. 1), hysterical tetanus (No. 2),* and strychnic poisoning (No. 3). 
The references in column No. 3 are to authorities who affirm that the 
symptoms there given are peculiar to poisoning. 


No. 1. 


Muscular symptoms usually 
commence with pain and stiff¬ 
ness of the back of the neck, 
sometimes with slight muscular 
twitcliiugs; come on gradually. 

Jaw one of the earliest parts 
affected; rigidly and persistently 
set. 


Persistent muscular rigidity, 
very generally with a greater or 
less degree of permanent opis¬ 
thotonos, emprosthotonos, pleur- 
osthotonos, or orthotonos. 


Consciousness preserved until 
near death, as in strychnic poi¬ 
soning. 


Draughts, loud noises, etc., pro¬ 
duce convulsions, as in strychnic 
poisoning. 

May complain bitterly of pain. 


No. 2. 

Commenced with blindness and 
weakness. 


Muscular symptoms commenced 
with rigidity of the neck, which 
gradually “crept over the body,” 
affecting the extremities last. 

Jaw rigidly set before a convul¬ 
sion, and remained so between 
the paroxysms. 

Persistent opisthotonos, and in¬ 
tense rigidity between the con¬ 
vulsions ; and after the convul¬ 
sions had ceased the opisthotonos 
and intense rigidity lasted for 
hours. 


Consciousness lost as the second 
convulsion came on, and lost with 
every other convulsion, the dis¬ 
turbance of consciousness and mo¬ 
tility being simultaneous. 


Desired to be fanned. 


Crying-spells, in which he 
“sobbed violently,” and “cried 
like a child,” alternated with the 
convulsions. 


No. 3. 

Begins with exhilaration and 
restlessness, the special senses 
being usually much sharpened.! 
Dimness of vision may in some 
cases be manifested later, after 
the development of other symp¬ 
toms ; but even then it is rare. 

Muscular symptoms develop 
very rapidly, commencing in the 
extremities, or the convulsion, 
when the dose is large, seizes the 
whole body simultaneously 4 

Jaw the last part of the body 
to be affected: its muscles relax 
first, and, even when during a 
severe convulsion it is set, it drops 
as soon as the latter ceases.§ 

Muscular relaxation (rarely a 
slight rigidity) between the con¬ 
vulsions, the patient being ex¬ 
hausted and sweating. If re¬ 
covery occur, the convulsions 
gradually cease, leaving merely 
muscular soreness, and sometimes 
stiffness like that felt after violent 
exercise. J 

Consciousness always preserved 
during convulsions, except when 
the latter become so intense that 
death is imminent from suffoca¬ 
tion, in which case sometimes the 
patient becomes insensible from 
asphyxia; If which comes on dur¬ 
ing the latter part of a convulsion, 
and is almost a certain precursor 
of death. 

The slightest “breath of air” 
produces a convulsion.** 

Patient may scream with pain, 
or may express great apprehen¬ 
sions, but “crying-spells” would 
appear to be impossible. 


* Column No. 2 is from an actual case. See trial of Mrs. Wharton, New York Medical 
Record, 1873. 

f Taylor, On Poisons, p. 683. Wormley, Micro-Chemistry of Poisons, p. 536. 

J Wormley, p. 536. Still€, Therapeutics, vol. ii. p. 148. 

£ Taylor, On Poisons, pp. 134, 682. Wormley, pp. 536, 540, 541. Tardieu, Sur VEm- 
poisonnement, p. 924. 

|| Taylor, On Poisons, pp. 134, 136, 682. Wormley, pp. 536, 540, 541. Tardieu, pp. 924, 
938, 939. Husemann, Handbuch der Toxicologie, p. 168. 

Wormley (1st ed.), p. 536. Taylor, Medical Jurisprudence, pp. 331, 332. Wharton and 
Still6, Medical Jurisprudence, paragraph 757. Tardieu, p. 923. Still6, Therapeutics, p. 148. 

** Stills, Therapeutics, p. 148. 



266 


GENERAL REMEDIES. 


No. 1. 

Eyes open, rigidly fixed, during 
the convulsion. 


No. 2. 

Eyes closed. 

The spasms in leg must have 
been partial, as the feet were 
crossed and toes inverted, which 
could not happen if all the mus¬ 
cles were involved, because the 
muscles of eversion, being very 
much the stronger, would of ne¬ 
cessity overcome the antagonistic 
muscles, and the feet be everted. 


No. 3. 

Eyes stretched wide open.* 

Legs stiffly extended, with feet 
everted,! as the spasms affect all 
the muscles of the leg. 


Death from strychnine in man and other mammals mostly occurs in 
a convulsion, and under these circumstances is undoubtedly due to as¬ 
phyxia. caused by the unyielding spasmodically-contracted muscles. In 
frogs, death must occur from other causes, since a frog, as shown by 
Claude Bernard, will live for days after removal of its lungs, probably 
by breathing through its skin. The causes of death in the frog are not 
hard to find when the physiological action of the drug is known. The 
lymph and true hearts (Kdlliker, loc. cit.; Harley, Lancet, July, 1856) 
are very much affected, but the chief factor is no doubt paralysis of the 
motor nerves. In man, death sometimes occurs not in a paroxysm, but 
during relaxation, and probably then is the result not only of the ex¬ 
haustion following effort, but also of the direct action of the poison on 
the nerves. 

The minimum fatal dose of strychnine is probably something under 
half a grain; the latter quantity has several times produced death, 
once in a man in twenty minutes ( Guy's JJosp. Rep., 1865, vol. xi. p. 
208); one-third of a grain given at intervals in fractional doses has 
produced such alarming symptoms as to indicate that in a single dose 
it might readily destroy life; one one-hundredth of a grain is said to 
have killed a child three and a half months old ( Pharm. Journ. and 
Trans., viii. 1010); but ten grains (Tschepke, Deutsche Klinik, 1861), 
twenty grains (A. E. Connor, Ohio Med. Recorder , 1879, 12), also twenty- 
two grains (Dr. Geo. Gray, Brit. Med. Journ., 1880, i. 477) taken on a 
full stomach and retained two hours, have failed to cause death, in each 
case probably on account of slow absorption. 

In treating poisoning by strychnine, a chemical antidote should be 
at once administered, such as tannic acid, or iodine or one of its soluble 
salts. As, however, the compounds formed in the stomach by these 
substances are not permanent, a quick emetic must follow their admin¬ 
istration. For the treatment of the symptoms, various substances have 
been recommended. Aconite, Calabar bean,J tobacco, or their alkaloids, 
would appear to be indicated as physiologically antidotal. The evidence 


* Still6, Therapeutics, p. 148. Wormley, p. 536. Tardieu, p. 924. 
t Tardieu, p. 924; also other authorities, which I have neglected to note, and at present 
writing have not at hand. 

| For two cases of recovery very doubtfully attributable to Calabar bean, see Ohio Med. 
Recorder, iv. 154. 



EXCITO-MOTORS. 


267 


brought forward by Dr. Haughton and others is not sufficient to establish 
clearly the especial value of tobacco, and in the experiments of M. 
Amagat (Journ. de Therap., 1875) nicotine seemed to have no power in 
preventing the death of rabbits which had received a fatal dose of 
strychnia. Further, it is obvious that the use of aconite, or of tobacco, 
in large doses, is accompanied with grave dapger, on account of their 
influence upon the heart, and we have in bromide of potassium a 
substance devoid of any such objection, and apparently as complete a 
physiological antidote to strychnine as are any of the substances above 
named. The chief question is as to whether the bromide has sufficient 
power and swiftness of action. In Dr. C. L. Bard’s case* ( Phila. 
Med. Times , i.), recovery after the ingestion of three grains of the 
alkaloid, without vomiting, occurred under the exhibition of a half¬ 
ounce dose of the potassium salt and “its continued use in smaller doses 
for an hour or so.” The symptoms were as intense as was consistent 
with life, but general relaxation was produced in thirty minutes after 
the administration of the counter-poison. 

Chloral was stated by Liebreich, its therapeutic discoverer, to be 
antagonistic to strychnine, and it undoubtedly is so in a measure; but 
M. Orr ( Gazette Medicate, July 6, 1872) stated to the French Academy 
that he had experimentally proved that the dose of chloral which Lieb¬ 
reich had relied on as being mortal to rabbits was very often not so, 
that the same was true of strychnine, and that consequently the inves¬ 
tigation of Liebreich was not to be relied on as proving the respective 
antidotal powers of the drugs; and, further, that experiments had 
shown him that if a certainly-fatal dose of chloral were given to a 
rabbit, the hjqoodermic injection of strychnine did not affect the result, 
but that his own researches had not gone far enough to establish the 
exact relations of the drugs. Professor Bennett (Brit. Med. Journ., 
vol. ii., 1874) has made an elaborate study, which agrees with the ex¬ 
periments of Orr in showing the non-efficiency of strychnine in chloral¬ 
poisoning, but also proves that chloral is of great value in poisoning 
by the alkaloid. Out of twenty-one rabbits which had received much 
more than the minimum fatal dose of strychnine (gr. to the pound), 
fifteen were saved by the use of chloral, and a few days later were 
killed in from ten to twenty minutes by a repetition of the original 
doses of strychnine. Dr. Bennett found that the chloral administered 
after the supervention of convulsions had less effect in saving life in 
direct proportion to the length of time between its administration and 
that of the poison. Professor Husemann (Arch. f. Exper. Path, und 
Therap., x.) found it possible to prevent death by chloral in rabbits 
which had received five or even six times the minimum fatal dose of 
the alkaloid. In various cases recovery from the effects of large doses 


* For other successful cases, see New Remedies, vol. ii. p.'255; also, Chicago Medical 
Examiner, 1879, xxxix. 280. 




268 


GENERAL REMEDIES. 


of strychnine (four grains, Edinb. Med. Journ ., April, 1875 ; six grains, 
Arch. Gen. de Med., 1883, i. 74, where also numerous cases may be found) 
has been brought about by the use of chloral, which must be at present 
considered a standard remedy in strychnine-poisoning. Alcohol has 
been strongly recommended by some authorities (Amagat, Stacehini) 
as antidotal; and when the great muscular relaxation of drunkenness 
is remembered, it seems very probable that the commendation has some 
basis. Professor Husemann (loc. cit .) has, however, shown that alcohol 
oan scarcely be looked upon as a real antagonist to the alkaloid. 

The best treatment of strychnine-poisoning is apparently to be found 
in the conjoint use of chloral and the bromide of potassium, with, when 
convulsions are very threatening, inhalations of nitrite of amyl, ether, 
or even chloroform. Half an ounce of the bromide with half a drachm 
to a drachm of chloral may be given at once in a severe case; and 
every twenty minutes afterwards, if necessary, two drachms of the 
first and fifteen grains of the second remedy. 

In some cases artificial respiration might possibly be of service. It 
is evident that the convulsed muscles will often resist such efforts as 
are usually made to force air into the lungs of man as successfully as 
they do the unassisted struggles of nature; and Harley states that he 
has found artificial respiration of no use whatever in animals. On 
the other hand, Leube (Arch. Anat. u. Physiol ., 1867), in an apparently 
very careful series of experiments, found that artificial respiration has 
great influence in saving or prolonging life, according to the amount of 
the poison ingested. In his experiments, the dose which ordinarily 
produced convulsions did not do this so long as artificial respiration 
was kept up; and the “ lethal dose” did not kill if artificial respiration 
was maintained for four hours, although opisthotonos was induced in 
some cases. Jochelsohn only succeeded in prolonging life ( Possbach's 
Untersuchungen, i. 92), but Rosenthal, according to Husemann, obtained 
similar results to Leube, and M. Schiff ( Schmidt's Jahrbucher , Bd. cxli. 
p. 43) has, in a series of experiments, corroborated in the main facts 
the results of the German investigators, although disagreeing with 
them in minor particulars. He found that animals in which forcible 
artificial respiration was maintained survived doses much larger than 
those ordinarily fatal. The artificial respiration was performed by 
inserting a canula into the trachea and filling the lungs by force. 
Klapp also found artificial respiration of service. Hone of the ordi- 
naiy methods of artificial respiration in man are, however, sufficiently 
powerful to be of any value. 

Administration.— As a tonic, strychnine may be given in pill; but 
when it is desired to push it until its physiological effects are manifested, 
as in some cases of paralysis , it should be always administered as the 
sulphate in solution, because death has occurred from an irregularity in 
the solution of the pills in the alimentary canal and the consequent 
simultaneous letting loose of a large amount of the alkaloid. There is 


EXCITO-MOTORS. 


269 


no proof of a cumulative action of this alkaloid when given as above 
directed. The dose of strychnine and its salts as a bitter tonic is from 
one-twentieth to one-thirtieth of a grain. In nervous diseases and 
other affections when pronounced influence is necessary, the dose should 
be gradually increased until muscular twitching, stiffness of the neck 
or legs, or other symptoms are manifested. 

Strychnine Sulphas. U. S. —Sulphate of Strychnine occurs in 
minute, prismatic crystals. It is soluble in water, and therefore pref¬ 
erable to the alkaloid for hypodermic use. Dose, one-twentieth of a 
grain. 

Brucine.— Strychnine clings so closely to brucine that the physio¬ 
logical actions attributed to brucine have no doubt sometimes been 
caused by contaminating strychnine. There is good reason for sus¬ 
pecting that this happened in the elaborate investigation of L. Wint- 
zenreid ( Dissert. Inaug., Geneva, 1882), who found that brucine acts as 
a stimulant to the spinal cord and a paralyzant to the motor nerves, 
but does not influence the cerebrum or the sensory nerves: in the 
higher animals, at first it increases the arterial pressure, and afterwards 
lessens it, paralyzes in large doses the vagi, causes death by asphyxia, 
and in other ways acts like strychnine. The more recent experiments of 
Lauder Brunton ( Journ. Chenx. Soc., 1885) are in accord with the results 
obtained by Wintzenreid in showing that brucine causes spinal convul¬ 
sions in mammals when injected directly into the circulation. Brunton 
found, however, that when taken by the mouth it produces no symp. 
toms, probably because it is excreted as rapidly as it is absorbed. Dr. 
Thomas J. Mays discovered that brucine, which he believed to be chem¬ 
ically pure, causes when injected hypodermically into the frog a short 
period of motor paralysis succeeded by convulsions of spinal origin, 
without impairment of general sensibility, and finally death from as¬ 
phyxia. Brought in contact with the isolated frog’s heart, it at first 
increased distinctly the rapidity and force of the beat, and finally 
arrested it in diastole. When locally applied to the nerves of the frog, 
it rapidly produced a paralysis of the sensory fibres. This led Dr. Mays 
to test it as a local anesthetic in man, and ho found that a five- or ten- 
per-cent. solution applied to the mucous membrane of the mouth caused 
rapid loss of sensibility. It is also asserted to exert a marked influence 
on the skin, a twenty-per-cent, solution applied to the back of the hand 
causing pronounced impairment of sensibility. Dr. Mays used this 
solution with excellent results for the relief of the itching of chronic 
pruritus. Dr. Ralph W. Zeiss ( Therap. Gaz., vol. xviii. p. 459) and Dr. 
Charles II. Burnett have found that the application of a five-per-cent, 
solution in cases of inflammation in or about the external ear usually 
gives very marked relief. Dr. Burnett states that his results were far 
more satisfactory than those which he has obtained with cocaine. In 


270 


GENERAL REMEDIES. 


using the brucine as a local anaesthetic it is essential that it be chem¬ 
ically pure: the nitrate or the sulphate may be selected, and one drop 
of hydrochloric or sulphuric acid should be added to the solution for 
each three grains of the alkaloidal salt. 

Ignatia. U.S.—The seeds of Strychnos Ignatia, a tree growing in 
the Philippine Islands. The St. Ignatius Beans are pale brown, about 
an inch in length, less in breadth, often angular, with three or four 
faces, covered with a very fine, scarcely visible down. They have been 
compared by some to an olive in size and appearance. They contain 
largely of the igasurates of strychnine and of brucine, and are identi¬ 
cal in their therapeutic value with nux vomica. The only officinal 
preparations are the abstract (Abstractum Ignatice, U.S.), dose, one grain, 
and the tincture {Tinctura Ignatice —1 to 10, U.S.), dose, twenty minims; 
the dose of the extract (Extractum Ignatice , U.S. 1870) is one-fourth to 
one-half a grain. 


FAMILY VI.-DEPRESSO-MOTORS. 


Under this heading are considered certain drugs which are used for 
the purpose of lessening the activity of the spinal cord. They have, 
except in this particular, but little in common in their action, and must 
be studied individually. 

PHYSOSTIGMA-CALABAR BEAN. U.S. 

An irregular, kidney-shaped bean, about an inch in length and three- 
fourths of an inch wide, the product of the Physostigma .venenosum, 
a perennial woody creeper of Calabar, Africa, where the bean has been 
used by the natives as an ordeal test for criminals, witches, etc., since 
time immemorial. It contains an alkaloid known as physosti.gmine, or 
eserine. The most reliable tests for the alkaloid are as follows. A 
watery solution of it or of its salts containing potassa, soda, or lime, 
on exposure to the air, becomes red, and finally yellow, green, or blue: 
this is said to occur when only one one-hundred-thousandth part of the 
alkaloid is in the solution. Chloride of gold throws down from the solu¬ 
tion a blue precipitate, out of which the gold is soon reduced. Accord¬ 
ing to Dr. J. B. Edwards (Med. Times and G-az., 1864), with strong sul¬ 
phuric acid and bichromate of potassium physostigmine yields a violet 
color, passing into red. This point needs investigating, in relation to 
the well-known strychnine test. The physiological test consists in the 
placing of a drop of the suspected solution in the eye of a rabbit, when, 
if physostigmine be present, contraction of the pupil will be produced 
in from eight to twenty minutes. A second alkaloid, calabarine * has 
been found by E. Harnack and L. Witkowski (Arch. f. Experim. Path, 
u. Pharm., Bd. v.) in especial abundance in commercial extracts. As 
Professor Harnack has succeeded in producing it from physostigmine 
(Ibid., Bd. xii.), it is a natural suspicion that it is formed by decomposi¬ 
tion of the physostigmine during the preparation of the extract. It is 
much less soluble in ether than is physostigmine, from which it may be 
separated by means of that menstruum. 


* Calabarine, according to its discoverers, is a tetanizing agent resembling strychnine in 
its action upon frogs and other of the lower animals. Professor Husemann found, however, 
that Merck’s “ calabarinum purum” acts in an entirely dissimilar manner; but Harnack has 
shown that this commercial article contains little or no calabarine (see Arch./. Exper. Path. u. 
Pharm., viii. 125; ix. 434; x. 301). It is possible that physostigmine has a strong tend¬ 
ency to undergo various decompositions, and to produce under different circumstances diverse 
derivative alkaloids. 


271 




272 


GENERAL REMEDIES. 


Physiological Action.— When an animal receives a small fatal 
dose of Calabar bean, after a time muscular tremors appear, and almost 
immediately the animal falls to the ground, or lies down, in a state 
of perfect muscular flaccidity. The pupils generally contract, and the 
respirations become slow, irregular, and often stertorous. All reflex 
actions are almost at once diminished, and this diminution grows 
greater and greater, until it ends in their complete abolition. So long 
as the condition of the motor system allows of it, evidences of sensi¬ 
bility are manifested whenever the animal is in any way injured. Ac¬ 
cording to Clementi Papi ( Schmidt's Jahrb., Bd. cxlii. p. 287), the voice 
is completely lost. The muscular tremors persist during the whole 
period of paralysis, and, indeed, even after cessation of the respiration. 
They vary greatly in intensity, and in some cases are so severe (Fraser) 
as to simulate general convulsions. As the minutes go by, the rhythm 
of the respiration becomes more and more affected, and at last death 
takes place quietly, consciousness being preserved until the last few 
gasping respirations close the scene. The pupils sometimes, but not 
always, dilate immediately after death. According to the experiments 
of Dr. Fraser, the bodily temperature is slightly elevated. 

After a small lethal dose of the poison, the fatal result is always duo 
to failure of the respiration, and if the body be at once opened the heart 
is found still beating; indeed, it has been seen to continue to do so for 
one and a half hours after death (Fraser). If a very large amount of 
the drug be given, the animal falls almost at once, paralyzed, with only 
a few muscular twitchings. The pupils contract, and in a very short 
time the gasping respiration ceases. The heart is now found distended 
and passive, but often will contract under the stimulation of a galvanic 
current. 

Tremors have been seen after the administration of the so-called pure 
physostigmine by Rossbach and Frohlich. Kohler, Rossbach, and others 
have even affirmed that Calabar bean produces a tetanic intoxication. 
A plausible explanation of these singular observations, and of many of 
the discrepancies of authorities, is to be found in the discovery of cala¬ 
barine. Its discoverers state that it produces first a violent tetanus, and 
afterwards paralysis. It is plain how its presence in varying amounts 
in Calabar bean preparations would modify their action. The researches 
of Kohler, of Yintschgau, and of Rossbach and Frohlich are especially 
open to doubt, on account of their statements that Calabar bean tetan- 
izes. It is very probable that the extracts used by them contained a 
notable percentage of calabarine. 

The symptoms induced by the drug in man are completely parallel 
with those that occur in the lower animals. They are giddiness, less¬ 
ened heart-action, great muscular weakness, with, in most cases, con¬ 
traction of the pupil, and sometimes with vomiting, and still more 
commonly with purging, which may be very free. A pupil of Gubler 
took 0.15 grain of the sulphate of eserine, and suffered, after a time, 


DEPRESSO-MO TORS. 


273 


nausea, giddiness, and intense muscular weakness, so that he could not 
stand; three-quarters of an hour afterwards he vomited some of the 
solution mixed with bile, but his strength did not begin to return for 
two and a half hours. 

The question here naturally arises, To what is the paralysis so 
prominent in poisoning by Calabar bean due ? It is evident that the 
suspension of reflex action can have only three sources,—paralysis of 
the spinal cord, of the nerve-trunks, or of the muscles. I shall examine 
the action of the drug upon these organs in inverse order. 

Muscles. —The muscular twitchings which have already been spoken 
of have been mistaken for convulsions by M. Yintschgau ( Sitzungsb. der 
Matli.-Nat. Classe d. k. Akad. d. JVissenschaften, Wien, 1867, Bd. lv., Abth. 
ii. p. 49), who, indeed, concluded that Calabar bean acts like strychnine, 
because violent convulsive tremors occurred, after injection of a dose of 
the poison under the skin, in all parts of a frog whose iliacs he had tied. 
Evidence to be brought forward hereafter, however, shows conclusively 
that there was some fallacy in this experiment. The fact that the mus¬ 
cular movements continue after death indicates that they are due to a 
direct action of the drug upon the muscles themselves. This conclusion 
is thoroughly established by the experiments of Laschkewich ( Virchow's 
Archiv, 1866, Bd. xxxv. p. 294), of Fraser (loc. cit .), and of Leven and 
Laborde ( Schmidt's Jahrb., Bd. cxlvi. p. 136). All of these investi¬ 
gators have noted that after death these contractions are increased by 
exposure to the air and by direct stimulation of the muscles; and 
Fraser has found that they occur in the frog during life after section 
of the supplying nerve, and also in a muscle actually cut out of the 
body. Laschkewich has confirmed the latter fact in the case of warm¬ 
blooded animals, and Leven and Laborde have proved that previous 
destruction of the lower end of the spinal cord in a guinea-pig does 
not prevent the development of the muscular twitchings in the hind 
legs. Although Calabar bean does, therefore, have some direct influ¬ 
ence upon the muscles, } r et the paralysis produced by it is in no sense 
the result of this influence, which appears, indeed, to be of an exciting 
rather than of a paralyzing character, since at the time of death the 
contractility of the muscle is in no wise diminished: on the contrary, 
Fraser has noted that in poisoning by Calabar bean the supervention 
of rigor mortis and of loss of functional power in the muscle is very 
greatly delayed. 

Nerves. —The paralysis caused by the physostigma is not due to an 
action on the nerve-trunks, since Dr. Laschkewich, Dr. Yintschgau 
(loc. cit., p. 161), and also Dr. Fraser, have found that when the gal¬ 
vanic current is applied to the crural nerve of either cold- or warm¬ 
blooded animals rapidly killed with Calabar bean, contractions are 
freely induced in the tributary muscles. 

Indeed, the Scotch investigator, carrying his experiments still 
further, and using delicate instruments which it i& not necessary here 

18 


274 


GENERAL REMEDIES. 


to describe, discovered that Avhen the artery going to a hind leg Avas 
tied in a frog before the administration of the poison, after a quick 
death the rate of conduction of impulse was as rapid in the nerve to 
Avhich the poison had had free access, as in its protected felloAV. Not¬ 
withstanding these facts, the drug is not entirely without influence 
upon the nerves, since Dr. Fraser has found that Avhen the blood-ves¬ 
sels of a frog’s leg are tied, and the animal sloAvly poisoned by a small 
dose of the extract, while even many minutes after cessation of respi¬ 
ration both nerves seem equally intact, yet finally a time comes Avhen 
the nerA r e of the poisoned leg refuses to react to the galvanic stimulus, 
although the functional power of the protected nerA r e, as well as of the 
muscles, is still perfect. This loss of functional power is probably 
rather in the termination of the nerve than in the trunk, for Dr. 
Fraser found that Avhen all the blood-vessels supplying the gastrocne¬ 
mius muscle were cut in a frog and the animal poisoned, at a certain 
time irritation of the crural nerve produced spasms of the gastrocne¬ 
mius alone. It is to be noted that this perturbation of the peripheral 
nerves has only been seen in the frog Avhen slowly poisoned, in Avhich 
case the heart continues to beat long after the cessation of respiration, 
so that the nerves are as it Avere macerated in a solution of the poison. 
Its existence even in this feeble degree is denied by Harnack and 
Witkowski. In frogs, and still more in warm-blooded animals, nerve- 
paratysis, if it exists at all, is of such slight intensity as to be of no 
practical importance. 

The afferent nerve-fibres probably preserA T e their function after the 
motor fibres have been affected, as Avas seemingly proved in Dr. Fraser’s 
experiments ( loc. cit., p. 19) by tying the vessels in the left leg of a frog 
which Avas afterAvards poisoned Avith strychnine, Avhen it was found 
that reflex movements Avere excited in the left leg by irritation of the 
right foot long after irritation of the left foot had ceased to cause 
movements in the right leg. 

Dr. Fraser studied to some extent the effect of a strong solution of 
the poison when applied locally to a nerve, and found that the efferent 
fibres were affected before the afferent, and that finally the function of 
both of them was abolished. 

Spinal Cord. — Since the abolition of reflex activity has its origin 
neither in the muscular system nor in the nerve-trunks, it must be 
spinal. The truth of this conclusion arrived at by exclusion has been 
abundantly demonstrated by direct experiment. Thus, Fraser, Har- 
nack, Witkowski, and others have found that if in the frog a peripheral 
nerve be protected by tying its artery and the batrachian be poisoned 
with Calabar bean, the paralysis in the protected limb occurs pari 
passu with that in the remainder of the body. Again, Fraser divided 
the spinal cord of a frog, and then cut or tied all the blood-vessels going 
to the posterior section of it. After this, the animal was poisoned with 
pbysostigma, and, while the usual symptoms developed themseh r es in 


DEPRESSO-MO TORS. 


275 


the anterior portion of the body, reflex actions were unaffected in the 
posterior part. Further, Dr. Fraser has found that when the poison is 
applied directly to the cord, fibrillary contractions, due probably to a 
local irritant influence, are induced in the muscles supplied from below 
the point of application, but in a little while all movements cease, and 
even galvanization of the cord is itself unable to elicit response. It 
seems completely established by the evidence which has been brought 
forward that the most prominent effect of Calabar bean is a depressant 
action upon the spinal centres. 

Recently, however, it has been asserted by Papi ( Schmidt's Jahrh ., 
Bd. cxlii. p. 287) that there is in frogs, preceding the stage of depres¬ 
sion, one of exaltation of reflex action; and also, on the strength of 
some experiments upon animals with one-sided section of the optic 
thalamus, that the cause of loss of voluntary movement in Calabar 
bean poisoning is paralysis of the conducting fibres passing from the 
upper brain to the spinal centres. I have not been able to procure the 
original paper of Dr. Papi ( Gazz. Lomb ., 1868), but his conclusions 
seem to me highly improbable. The primary stage of reflex activity 
probably was produced by calabarine present in the extract used by 
him. 

Circulation .—Harley ( loc. cit., p. 151) and Papi (loc. cit., p. 287) 
assert that Calabar bean has little or no influence upon the heart; but 
they are undoubtedly in error. According to Harnack and Witkowski, 
in the frog under the influence of the poison the heart’s contractions 
become slower and stronger. When a mammal is poisoned with small 
doses, the cardiac action of the drug is suboi’dinate to that upon the 
nerve-centres; but, as has been shown by Dr. Fraser, when very large 
doses of the poison are administered, especially if they be injected into 
the jugular vein, death results from syncope or from consentaneous 
failure of the cardiac and the respiratory functions, and the heart is 
found arrested in diastole, flaccid, but, according to Dr. Fraser and to 
Drs. C. Arnstein and P. Sustschinsky ( Untersuch. Physiolog. Laborator. 
Wurzburg , Theil ii. p. 86), responding, though feebly and uncertainly, 
to direct stimulation. In the frog, Rossbach and Frohlich ( Pharmak. 
Untersuch , i. p. 56) have found that the arrested heart is insensible 
to stimuli. 

When smaller doses of the poison are exhibited, there is slowing 
of the heart’s action, as has been noted by Laschkewich (loc. cit., p. 
298), by Fraser (loc. cit., p. 48), by Dr. J. Tachau (Archiv der Heil- 
kunde, 1865, p. 70), and by other observers. Although, according to 
the experiments of Dr. Fraser, there is at first a slight fall of the 
blood-pressure, which is probably due, as he believes, to diminished 
pulse-frequency, yet, in spite of the continuance of the slow pulse, 
the arterial tension soon recovers itself, and remains for a long time 
much above the normal point, while at the same time the individual 
cardiac beats are greatly increased in strength (Fraser, Bezold and 


276 


GENERAL REMEDIES. 


Gotz*). Finally, the arterial pressure falls far below normal, and the 
power of the heart is gradually extinguished. 

The question as to the exact method in which these changes are 
wrought is of very difficult answer. The long diastolic pauses and the 
slow strong beat of the heart suggest at once that a chief action of 
the drug is upon the inhibitory cardiac nervous system. Tachau, how¬ 
ever ( loc. cit., p. 172), found that after section of the vagi the poison 
produces these phenomena in an even more intense degree than in the 
normal heart. As this has been confirmed by Laschkewich (loc. cit.), 
by Fraser (loc. cit., p. 49), and by Harnack and Witkowski (loc. cit., p. 
419), it must be accepted as a proved fact, especially since Yintschgau 
has found (loc. cit., p. 71) that if in the frog the brain and the medulla 
be destroyed, physostigmine still acts in its usual way on the heart.f 
Tachau considers that this demonstrates that the cardiac phenomena 
of Calabar bean poisoning are not due to an action of the drug upon 
the inhibitory nerves. Arnstein and Sustschinsky, however, admitting 
the fact, deny that it warrants the conclusion. Their idea appears to 
be that it is conceivable that a substance should so act upon the periph¬ 
eral inhibitory nerve-endings as to cause them to influence the action 
of the heart without any external impulse, and consequently when 
separated from the nerve-centres. Kohler, Harnack, and Witkowski 
have all found that in the frog Calabar bean still lessens the pulse-rate 
after complete paralysis of the peripheral vagi by atropine | (Archiv 
f. Exper. Path. Pliarm., Bd. i. p. 280). Kohler believes that his ex¬ 
periments prove that the Calabar bean paralyzes the cardiac accele¬ 
rator nerves. It will be remembered, however, that Yintschgau found 
that Calabar bean exerts its normal influence upon the heart after de¬ 
struction of the accelerator centres. Whatever may be the action of 
small doses of physostigmine upon the vagi and accelerators, it seems 
to me that it must be considered established that the general cardiac 
symptoms are due to a direct action upon the heart-muscle or its con¬ 
tained ganglia. 

In regard to the action of the drug upon the peripheral vagi, the 
following resume of the evidence is of interest. Arnstein and Sus¬ 
tschinsky found that the excitability of the peripheral cardiac vagi is 
increased by Calabar bean. They first tested the effect of graduated 
galvanic currents applied to the divided vagi in the animal to be ex- 


* I have not seen the original paper of these authorities in the Centralblatt fur Med. 
\Vi88emchaft, 1867, but quote them from the paper of Arnstein and Sustschinsky. 

f The fact that Calabar bean acts in its usual manner after section of the par vagum indi¬ 
cates that it has no influence upon the inhibitory centres,—a conclusion confirmed by Arnstein 
and Sustschinsky (loc. cit., p. 102), who found that an injection of the drug into a carotid— 
i.e., into the inhibitory centre—did not cause any marked immediate diminution in the num¬ 
ber of the cardiac pulsations. 

| Rossbach and Frohlich (loc. cit., p. 56) assert that in frogs, although the vagi are not 
more excitable before than after the poisoning, stimulation of the venous sinuses and of the 
auricles has much more than the normal influence,—which is very extraordinary, if true. 



DEPRESSO-MO TORS. 


277 


perimented with, until the exact strength of the weakest current 
capable of causing diastolic arrest was demonstrated, and then exhib¬ 
ited the drug and tested the nerves afterwards. They used in these 
experiments both rabbits and guinea-pigs, and found that, without a 
single exception, currents much weaker than those which previously 
were barely effective would, after the poisoning, stop the heart; also 
the super-excitability of the peripheral inhibitory nerves was shown 
by the fact that under the influence of the drug the diastolic arrest 
continued much longer than normal after the withdrawal of the stim¬ 
ulus from the vagi. These experiments have been directly corrobo¬ 
rated by Rossbach and Frohlich upon the rabbit ( loc. cit., p. 57). Dr. 
Fraser’s experiments upon the local cardiac application of the drug 
are also seemingly confirmative of those of Arnstein and Sustschinskj', 
for he found that when the poison was put directly on the heart, or 
into one of its chambers, it caused a prolonged diastolic pause, followed 
by contractions interrupted by pauses, and finally by resumption of reg¬ 
ular contractions, or else by diastolic arrest, the heart still retaining 
its power of responding, in an embarrassed manner, to stimuli. These 
experiments certainly seem to prove that Calabar bean does cause 
excitation of the peripheral cardiac apparatus. Arnstein and Sus- 
tschinsky further confirm them by other experiments of much in¬ 
terest. They injected into rabbits such amounts of atropine as com¬ 
pletely to paralyze the peripheral cardiac vagi, so that the strongest 
currents when applied to the nerves failed to influence the heart’s 
action, and then restored functional power to the pneumogastrics by 
injections of Calabar bean, so that currents of moderate intensity caused 
diastolic arrest. These experiments, if accurate, prove that physostig- 
mine is a powerful excitant of the peripheral vagi. Kohler (loc. cit.), 
using the frog, and Rossbach and Frohlich, using the rabbit, failed to 
resuscitate the atropinized vagi by means of Calabar bean, but it is 
evident that a negative result in such a case might be due to an im¬ 
proper proportion in the doses of the counter-poison, or to the atropine 
being employed in overwhelming amount. In warm-blooded animals, 
at least, the vagi are not paralyzed during life by physostigmine, as 
is evinced by the experiments of Arnstein and Sustschinsky (loc. cit., p. 
101), confirmed by Harnack and Witkowski (loc. cit., p. 433). Some of 
the results obtained by Fraser (loc. cit., p. 36), confirmed by Rossbach 
and Frbhlich, apparently contradict but in reality accord with them. 
In the frog there was, indeed, at last a loss of functional power in the 
vagi, but not until very long after the cessation of respiration, after all 
the nerves of voluntary motion had lost their functional power,— i.e., 
after death would have occurred in a mammal. Harnack and Witkow- 
ski affirm that the vagi never lose their power in the frog to lessen the 
rate of the heart-beat, although unable to cause diastolic arrest. 

In summing up the evidence in regard to the action of the drug 
upon the vagi it is plain that no positive conclusion can be reached, 


278 


GENERAL REMEDIES. 


although it seems probable that the drug first increases and then lessens 
the power of the inhibitory nerves over the heart. 

As already stated, a very prominent phenomenon in Calabar bean 
poisoning is rise of the arterial pressure. This, of course, may be of 
cardiac origin, or it may be due simply to a contraction of the arte¬ 
rioles, or it may arise from a combination of these causes. Bezold and 
Gotz (quoted by Arnstein and Sustschinsky, p. 87) found that the 
arterial pressure still rose under the influence of the drug after section 
of the spinal cord high up,— i.e., after general vaso-motor paralysis. 
Harnack and Witkowski also found that when the vaso-motor centres 
were paralyzed with chloral, physostigmine caused very decided increase 
of the arterial pressure. It is evident that the increased force of the 
circulation produced by physostigmine must, at least in part, bo due 
to a direct action of the drug on the heart. 

The fact that the rise of arterial pressure produced by Calabar bean 
is not so great in animals whose cords have been divided as in those 
uninjured certainly indicates, though it does not prove, that the in¬ 
creased arterial tension of physostigmine-poisoning is in part due to vaso¬ 
motor spasm. Dr. Fraser believes that Calabar bean does produce this 
spasm; but his evidence is insufficient to establish his conclusion. It 
consists simply of some experiments upon frogs in which the spinal 
cord was divided, and, the animal being put on a “ frog-plate,” the 
arteries of the web were watched while Calabar bean was exhibited. 
Dr. Fraser believed that under these circumstances the arteries con¬ 
tracted considerably at first, and afterwards dilated. Dr. Harley ( Prac¬ 
titioner, 1869, iii. 163) states as the result of his studies that Cala¬ 
bar bean can be seen, when applied locally, to cause contraction of the 
veins, the arteries remaining unaffected ; while Dr. Fraser, in contradic¬ 
tion to this, believes that he has demonstrated that the local application 
of physostigma produces dilatation of the arteries. It is not necessary 
here to reiterate my objections to such evidence as this. If, under the 
circumstances of the first-mentioned experiments of Dr. Fraser, Calabar 
bean contracts the small vessels, it must be by a peripheral, not centric, 
action, since the vessels were separated by the division of the cord from 
the vaso-motor centres. It is plain that this is in direct contradiction 
to Dr. Fraser’s experiments on the local application of the drug. Again, 
it is contradictory, rather than confirmatory, of that furnished by the 
study of the blood-pressure. The only logical conclusion seems to me 
to be that at present we have not proof that Calabar bean acts upon 
the vaso-motor nervous system. As the increase of the arterial pressure 
is in great part, if not altogether, due to the increased energy put forth 
by the heai't under the influence of physostigmine, and as that influ 
ence is exerted directly upon the heart-muscle or its ganglia, it is evident 
that physostigmine directly causes the heart to put forth more effort, or, 
in other words, stimulates it. The final diastolic arrest (the loss of the 
power of responding to stimuli) shows, however, that at last the poison 


DEPRESSO-MO TORS. 


279 


paralyzes the heart. In considering the general physiological action 
of the drug, it must not be forgotten that its influence upon the heart 
is entirely subservient to its influence on the nervous system,* and that 
death in the mammal occurs before the stage of cardiac palsy is reached, 
unless the drug be injected directly into the heart in overwhelming dose. 

I do not believe that physostigma has much action upon the blood. 
Certainly its influence upon the nervous system is a direct one, since 
Lewisson ( Reichert's Archiv, 1870) has found that it acts upon the “salt 
frog” as upon the normal animal. The alterations noted by Dr. Fraser 
in the blood are probably produced by the asphyxia which precedes 
death: these alterations are that the blood coagulates slowly and loosely, 
and the red disks in dogs and in rabbits present various irregularities 
of outline, among which may be noted a well-marked stellar crenation, 
but that the respiratory function of the blood is not interfered with. 

Intestines. —Intestinal peristalsis is very much increased by the action 
of Calabar bean (Westermann, Schmidt’s Jahrbucher , Bd. cxxxviii. p. 
290; Papi, Ibid., Bd. cxlii. p. 287; Fraser, loc. cit., p. 57). After poi¬ 
sonous doses there is at first a stage of exceedingly active movements 
in the bowels; then spasmodic tetanic contraction of the intestines 
occurs, so that their calibre is very much diminished; and finally relax¬ 
ation and dilatation take place. After death the vermicular movements 
are found very much lessened (Fraser), or altogether abolished (Tachau, 
loc. cit., p. 73). 

The action of Calabar bean upon the intestines appears to be periph¬ 
eral, due to contact of the poison in the blood with the muscular 
fibres or the ganglionic nerve-cells in the walls of the bowels. For 
Westermann (loc. cit., p. 291) found that extirpation of the cardiao 
ganglion had no effect upon the action of the drug, but that tying of 
the mesenteric and of the coeliac arteries, before poisoning, prevented 
any increase in the peristalsis. Calabar bean probably influences intes¬ 
tinal secretion. Its action upon the salivary glands is often decided, 
and according to Heidenhain is not prevented by atropine. 

Eye. —Calabar bean, as is well known, strongly contracts the pupil, 
both when applied to the eye and when exhibited internally. Evidently, 
as in the case of atropine, the pupillary action of Calabar bean should 
be studied from two points of view, the local and the constitutional. 

The closeness of the analogy between the pupillary action of atropine 
and that of Calabar bean is seen in the fact that, like the former, the 
latter, as shown by the experiments of Vee and Leven on chickens 
( Comptes-Rendus Soc. Biolog., 1865, p. 161), does not affect the irides of 
birds. Thus, analogy would seem to prove that the influence of Calabar 
bean is directly upon the peripheral nerves of the iris. 


* For a discussion of the peculiar cardiac relations of physostigmine and muscarine, see 
the paper by Ilarnack and Witkowski. Those authors believe that Calabar bean sets in motion 
the heart arrested in diastole, not by paralyzing the cardiac inhibitory apparatus, but by 
stimulating the cardiac muscle. 



280 


GENERAL REMEDIES. 


Although, then, I am not able to cite any direct experimental proof, 
yet it seems to me scarcely doubtful that the contraction of the pupil 
produced by Calabar bean is always a local, peripheral influence, whether 
the drug be placed in the eye from the outside or be carried through the 
general circulation. It is evident that the myosis may be caused in one 
of three methods,—by paralysis of the sympathetic fibres, by stimula¬ 
tion of the oculo-motor fibres, or by a conjoint action upon both sets of 
nerve-endings. In which of these ways the drug acts, we are not yet 
able to decide. 

It has been held by various authorities that if galvanization of 
the sympathetic fibres in the neck fail to expand a contracted pupil, 
the myosis must be due to paralysis of the sympathetic. Evidently, 
however, this is claiming too much, for, as pointed out by Griinhagen 
( Virchow's Archiv, Bd. xxx. p. 521), it is conceivable that an oculo¬ 
motor spasm can exist of such intensity that the antagonistic nerve is 
unable to dilate the pupil. The question arises very pertinently at this 
point, What is the fact in regard to Calabar-myosis ? Does or does 
not galvanic stimulation of the cervical sympathetic dilate the pupil? 
The testimony is somewhat conflicting. Dr. Griinhagen ( loc . cit ., p. 521) 
says that dilatation always occurs, although to a slight extent (in be- 
schrdnkten Masse) ; wdiile, on the other hand, Dr. Gustav Engelhardt 
(Untersuch. a. d. Physiolog. Laborator. in Wurzburg , Theil ii. p. 526) has 
found that galvanization of the cervical sympathetic has no effect upon 
the contracted pupil. The experiments of Fraser (loc. cit., p. 60), of 
Bernstein and Dogiel, and of Rosenthal (Beichert's Archiv, 1863), would 
seem to reconcile these differences, and, by their accord, to prove that 
under the maximum influence of Calabar bean the sympathetic is 
powerless, while when the contraction is the result of a milder influ¬ 
ence of the drug, stimulation of the cervical nerve will cause a certain 
amount of dilatation.* Fraser, and also Engelhardt, have found that 
if the poles of a battery be applied directly to an iris even most pro¬ 
foundly contracted by physostigma, immediate dilatation occurs. These 
facts, for reasons stated above, do not absolutely prove, but they cer¬ 
tainly render it highly probable, that Calabar bean paralyzes the periph¬ 
eral sympathetic nerve-fibres in the iris. It is, however, almost equally 
probable that there is a consentaneous stimulation of the oculo-motor 
terminations; for the myosis caused, like the mydriasis produced by 
atropine, is an active, not a passive, condition, and is not only much 
more forcible, but is also much more complete, than that which follows 
section of the cervical sympathetics. If the observation of Rossbach 
and Frdhlich be correct, that overwhelming doses of the physostigmine 


* Recently Rossbach and Frohlich affirmed that galvanization of the sympathetic still 
causes dilatation, even when the action of the physostigmine is most vigorous. As it is 
scarcely conceivable that the various other investigators should have been so much in error, 
it is probable that Rossbach and Frohlich used such strong currents that they were directly 
transmitted to the iris. 




DEPRESSO-MOTORS. 281 

finally dilate the pupil, it is evident that the oculo-motor stimulation is 
replaced after such dose by oculo-motor palsy. 

Urine and Elimination. —No study, that I am aware of, has been 
made either as to the elimination of physostigmine or as to its action 
on the urinary secretion in health. Dr. Merson ( Journ. Ment. Sci., Jan. 
1875) has found that in general paralysis under its influence urea and 
the other solids of the urine are decidedly diminished. The physostig¬ 
mine probably escapes with the renal secretion, and in a case of poison¬ 
ing its presence could probably be detected by dropping some of the 
fluid in the eye of an animal. 

Therapeutics.— The physiological action of Calabar bean has sug¬ 
gested its use in spasmodic affections, in atony of the muscular coats 
of the bowel, and in various diseases of the eye. 

The action of Calabar bean upon the spinal cord very early led to 
its use in spasmodic affections, and especially in tetanus , in which disease 
it has been more freely employed during the last few years than any 
other remedy except opium. In the paper of Dr. B. Roemer ( St. Louis 
Med. Surg. Journ., 1873, p. 367) are collected forty-seven cases, of which 
twenty proved fatal. To these I am able to add the twenty whose 
references are given below,* making in all sixty-seven cases, with thirty- 
seven recoveries and thirty deaths,—not a very flattering record. 

It is, however, proper to state, as affecting the value of these sta¬ 
tistics, that much of the Calabar bean extract which has been offered 
in the market is practically inert, and in all probability in some of these 
cases the drug did not have a fair trial; and that when especial care 
was taken by certain observers better results were achieved, although 
on so small a scale as to leave the issue in much doubt.f 

In trismus neonatorum , Calabar bean has been employed with results 
certainly no more encouraging than those obtained in tetanus. In 
chorea it has also been used by some practitioners with asserted advan¬ 
tage, but further experience hardly justifies its administration (see Bull. 
Gen. Therap ., lxxxix. 85, 541). 

The physiological action of physostigma upon the unstriped intes¬ 
tinal muscle-fibres has led to its employment in atony of the muscular 


# Fatal Cases. —Fenwick, 1 ( Glasgow Medical Journal, 1869, p. 300); Franzolin, I 
(The Doctor, Oct. 1, 1871); Laborde, 1 ( British Medical Journal, June, 1872); Valdivieso, 
1 (Philadelphia Medical Times, vol. i. p. 455; Tyson, 1 {Ibid., p. 418); Johnson, 1 {Ibid., 
p. 372); 1 {London Lancet, 1874); Silbermann, 1 {Charier’s Thesis, 1881); Delamarre, 1 
{Paris Thesis, 1875); Richelot, 1 {Thise de Concours, 1875). Recoveries. —Fenwick, 1 
{Glasgow Medical Journal, 1869, p. 300); Newman, 1 {Medical Examiner, July, 1869); W. 
W. Keen, 1 {Philadelphia Medical Times, vol. i. p. 195) ; J. H. Packard, 1 {Ibid., p. 138); 
Cunningham, 1 {British Medical Journal, i. 1874); 1 {Cincinnati Lancet, Sept. 1878). All 
these cases were of the traumatic form of the disease. Charier, 1 {Paris Thesis, 1881); 
Burnam, 1 {Lancet, Jan. 1881); Pooley, 1 {New York Med. Journ., Sept. 1878); Silbermann, 
1 {Charier’s Thesis, 1881). 

j- For a favorable record, see Watson, Glasgow Medical Journal, N. S., 1869, vol. i. p. 54; 
consult also London Practitioner, Sept. 1869. 



282 


GENERAL REMEDIES. 


coat of the bowels and other similar organs. Dr. Y. Subbotin ( Archiv 
f. Klin. Med., Bd. v. p. 285, 1869) has used the extract with the hap¬ 
piest results in a case of chronic bronchial catarrh with intense dyspnoea, 
believed to be due to weakness of the bronchial muscular fibres, and 
also in one of apparently “ phantom tumor," with chronic intestinal dys¬ 
pepsia and catarrh. In constipation dependent upon relaxation it is 
also said to be useful. Dr. A. Hiller strongly endorses the value of 
the extract in chronic intestinal atony, after or during a catarrh, in the 
convalescence from fever, etc., and in constipation with flatulence, in 
meteorism, etc. ( Charite-Annalen, 1883, 235). 

Calabar bean has also been employed in strychnine-poisoning, and a 
recovery obtained after the ingestion of three grains of the latter alka¬ 
loid is reported by Dr. J. W. Key worth ( Glasgow Med. Journ., N. S., 
1869, i. 54).* 

In epilepsy, some trials have been made of the drug, but its value is 
very doubtful. Drs. Harnack and Witkowski have found that in epi¬ 
leptic guinea-pigs physostigmine causes a succession of fits lasting for 
hours and days. They have further noted a similar influence upon 
man. Recently attention has been called to the employment of Cala¬ 
bar bean as a galactagogue, the extract being applied to the breast 
itself (Brit. Med. Journ., 1876, ii. 554). 

Administration. —Calabar bean is usually administered as an extract 
(Extractum Physostigmatis, U.S.), the commencing dose of which is one- 
tenth to one-fifth of a grain. The dose of the tincture ( Tinctura Physo- 
stigrnatis, U.S.) is twenty to forty minims. The alkaloid is preferable, 
on account of its certainty, but care is requisite not to use it too freely. 
Bouchut has found that in children one-twentieth of a grain, given 
hypodermically, will produce very decided symptoms, which entirely 
pass off in about three hours. It is probable that one-fifteenth of a 
grain, repeated every three hours, will be found to be a moderate dose 
for the adult. It should always be borne in mind that in tetanus and 
other severe diseases it is necessary to augment the dose until an effect 
is produced. Harnack gives the minimum fatal dose of eserine as for 
dogs four to five, rabbits three, cats two to three milligrammes. The 
frog resists these doses successfully. 

Toxicology.— So far as I know, Calabar bean has not been used, 
either in Europe or in this country, with criminal intent. In Liverpool 
seventy children were accidentally poisoned at one time (Med. Times 
and Gaz., Oct. 1864, p. 406). Many of the victims vomited spontane¬ 
ously, and thus relieved themselves. Those brought to the hospital 
were in a state of extreme prostration and muscular relaxation. They 
appeared to suffer almost no pain, only some of them saying they had 
a little “belly-ache.” Among some thirteen examined, only one had 


* The subject of the asserted antagonism between chloral and Calabar bean will be studied 
in the article on chloral. ' 



DEPRESSO-MO TORS. 


283 


the pupils contracted. The only child who did not recover was exces¬ 
sively weak, and, crying out suddenly, was dead of sudden syncope. 
The heart was found relaxed and flabby, both sides equally full of blood. 
In the case of a strong man, who had eaten half a bean (St. Barthol. 
Hosp. Rep., 1879, xv.), the symptoms were great muscular weakness, 
tightness across the chest, temperature of 96.6° F., very slow, inter¬ 
mittent, irregular pulse, and collapse, without vomiting, purging, con¬ 
traction of the pupils, or abdominal pain. 

In 1864 Dr. Kleinwiichter treated a case of poisoning by an unknown 
quantity of atropine with Calabar bean, apparently with great benefit. 
Dr. Bourneville detailed in 1867 some experiments which seemed to 
show that there is a real antagonism between Calabar bean and the 
mydriatic, and in 1870 (Revue Photograph, des Hopitaux ) published five 
experiments upon guinea-pigs, which were very decisive in that a 
proved fatal dose of physostigma was given in each case and recovery 
obtained by the use of non-lethal doses of atropia. In 1869 Professor 
Roberts Bartholow, of Cincinnati, on the strength of a few really inde¬ 
cisive experiments, arrived at a conclusion opposite to that of Bourne¬ 
ville. Recently, Dr. Fraser, of Edinburgh, has investigated the subject 
in so thorough a manner that his essay may serve as a model for those 
who are desirous of studying questions of antagonisms between poisons. 
His experiments, three hundred and thirty-one in number, were mado 
chiefly upon rabbits, a few having been upon dogs. He first investi¬ 
gated as to the minimum fatal dose, per pound of the animal, of the 
preparations used,—the extract of the bean, and the sulphate of eserine. 
It was ascertained that the minimum lethal dose for rabbits of the ex¬ 
tract of physostigma which he employed was 0.4 grain per pound ; of 
the sulphate of eserine, 0.04 grain per pound. Then in sixteen experi¬ 
ments in which recovery followed the administration of a dose of 
atropine given in combination with a dose of physostigma equal to or 
in excess of the minimum fatal dose, the animal used was killed long 
afterwards by a dose of the Calabar bean less than or equal to that 
from which recovery had occurred under the influence of atropine. In 
this way a perfect demonstration of the power of the counter-poison 
was obtained. 

It was found that the counter-poison acted most efficiently when 
thrown directly into the veins. Thus, a rabbit weighing three pounds 
and two ounces received 1.6 grains of the extract, and five minutes after¬ 
wards 0.02 grain of atropine, in a vein, and recovery took place; eight 
days after this, 1.3 grains of the extract killed the same rabbit in nine¬ 
teen minutes: in another animal which nine da 3 'S before had been saved 
from death after the exhibition of 2 grains of the extract by 0.5 grain 
of the sulphate of atropine, 1 grain of the extract proved fatal in 
thirteen minutes. 

The next series of experiments was undertaken to ascertain the 
maximum dose of physostigma that can be successfully antagonized 


284 


GENERAL REMEDIES. 


by atropine, and the dose in which the latter should be employed. In 
all cases the atropine was given five minutes before the Calabar bean. 
It was found that one-fiftieth of a grain of the mydriatic would suc¬ 
cessfully antagonize one and a half times, but not twice, the minimum 
fatal dose of the myotic. 

One-fortieth of a grain of the atropine was successful against two 
to two and a half times the minimum lethal dose of physostigma ; 
three-fiftieths was sufficient for three times the minimum fatal dose. 
The small size of the required doses of atropine is very noticeable, and 
at the present point in the investigation a very curious result was ob¬ 
tained. It was found that when three times the minimum fatal dose 
of the Calabar bean were exhibited, the successful dose of atropine 
ranged from three-fiftieths of a grain to one grain and a fifth. When 
three and a half times the fatal dose of the physostigma were exhibited, 
success was achieved only with doses of atropine of from one-tenth to 
one-fifth of a grain. Unfortunately, there are only seven experiments 
bearing upon this point; yet its general accuracy, I think, can scarcely 
be questioned. When a rabbit received four times the lethal dose of 
physostigma, the mydriatic was powerless. 

In the final series of experiments, the atropine was administered 
five minutes after the physostigma, and it was found that the largest 
dose of the latter which could be combated successfully was three 
times the minimum fatal dose, and the range of the dose of atropine 
was much less than when it was given before the poisoning. Thus, 
with three times the minimum lethal dose of the Calabar bean, death 
occurred when three-twentieths or one-fifth of a grain of the antidote 
was given, but recovery followed the administration of four-twenty- 
fifths of a grain. 

No experiments were made to test the value of physostigmine in 
atropine-poisoning. Dr. Fraser states, however, on what grounds I do 
not know, that the minimum fatal dose of atropine in rabbits is twenty- 
one grains; and he found that when one-lialf the minimum lethal dose 
of physostigmine is given, together with nine and four-fifths grains, or 
more, of atropine, death results. 

These experiments of Fraser have been in some degree confirmed 
by the imperfect researches of Amagat ( Journ. de Thei'ap., 187G). Con¬ 
siderations previously given, however, show that the cardiac antago¬ 
nism of atropine and physostigmine must be considered doubtful, and, if 
it exists, is of little importance. Whatever of life-saving power the 
mydriatic has in Calabar bean poisoning is evidently dependent upon 
its stimulant action on the respiratory centres. 

The question naturally arises, How far are the results of these ex¬ 
periments applicable to the treatment of Calabar bean poisoning in 
man? Without discussing this at length, I think the following deduc¬ 
tions are obvious: first, that atropine ought by all means to be tried in 
poisoning by physostigma; second, that the doses of it should never be 


DEPRESSO-MO TORS. 


285 


very large, not exceeding in all the tenth of a grain. The use of atro¬ 
pine should, of course, not cause neglect of such measures of relief as 
evacuation of the stomach, the external application of dry heat, etc., 
usual in poisoning by sedative narcotics. Artificial respiration should, 
when necessary, be assiduously practised, since death undoubtedly is 
due to failure of the breathing, and Harnack and Witkowski have 
found that animals survive very large doses of the poison when respira¬ 
tion is maintained artificially. 

POTASSII BROMIDUM-BROMIDE OF POTASSIUM. U.S. 

The bromide of potassium is prepared, according to the officinal 
method, by precipitating freshly-made solution of bromide of iron by 
the pure carbonate of potassium, filtering, and evaporating the result¬ 
ant solution. It occurs in milk-white cubic or quadrangular pris¬ 
matic crystals of an acrid saline taste, freely soluble in water and 
slightly so in alcohol. When it is mixed with starch, and chlorine is 
added, a yellow color is developed. A bluish tint betrays contamina¬ 
tion with an iodide. 

Physiological Action.— Local Action. — When a solution of the 
bromide is applied locally to the heart, it produces instantly marked 
lessening of its action, and, if in sufficient amount and concentration, 
even instantaneous diastolic arrest ( Virchow's Archiv, xli. 101). Upon 
the voluntary muscles it acts in a similar manner when similarly ap¬ 
plied. If its solution be not too concentrated or abundant, however, 
the muscle of the frog is first thrown into a tetanic spasm ( Dublin 
Journ ., xlvii. 325); and Dr. Purser suggests that the tetanic symptoms 
seen in the frog poisoned by the bromide of potassium are due to this 
action on the muscles. On the nerve-trunks, and also on the nerve- 
centres, the bromide acts, when applied locally, as a paralyzing poison 
(. Bull. Therap ., lxxiii. 253, 290; also Dr. Amory, Physiolog. and Therap. 
Action of the Bromide of Potassium , Boston, 1872, Part II., p. 147; also 
Ringer and Morshead, Journ. Anat., xii. 71). It is, therefore, evident that 
the bromide of potassium in sufficient quantity is a deadly poison to all 
the higher animal tissues. In general poisoning of animals by hypo¬ 
dermic injection of the bromide, this local action is often very mani¬ 
fest, and paralysis of the part into which the solution has been thrown 
follows very rapidly upon the injection. In the form of powder it is 
affirmed to be somewhat caustic, and has been highly recommended 
for the destruction of excessive granulations, etc. (Brit. Med. Journ., 
1876, ii. 496). 

General Action. —Bromide of potassium administered to frogs in 
minute doses produces as a first result a tetanoid condition, in which 
there may be very marked opisthotonos. After a short time this stage 
of muscular excitement gives way to one of great muscular relaxation 
and total abolition of reflex actions. Voluntary movements, however, 
often occur during this period, and the frog which has been lying limp 


286 


GENERAL REMEDIES. 


and apparently dead will startle the observer by a sudden vigorous 
leap. This fact has been so frequently witnessed that there can be no 
doubt of its truth. It is vouched for by the following observers: J. 
M. Purser ( Dublin Journ. Med. Sci., xlvii. 324, 1869) ; Lewisky aus 
Kazan ( Virchow's Archiv, Bd. xlv. p. 191, 1869); J. V. Laborde 
(.Archives de Physiol. Norm, et Pathol., t. i. p. 423, 1868, and Comptes - 
Pendus, t. lxv., 1867); MM. Damourette and Pelvette ( Bull. Therap., 
1867, lxxiii. 249). Very early in the paralytic stage the respiratory 
movements are affected, and they gradually grow less until their final 
arrest. When a very large dose of the bromide is given, death may 
be induced by paralysis of the heart (Albert Eulenberg and Paul Gutt- 
mann, Virchow's Archiv , xli., 1867); but after a small toxic dose this 
viscus continues to beat long after the cessation of breathing. If the 
drug be given by an injection practised in the vicinity of the heart, 
sudden cardiac arrest always occurs. 

Upon mammals {Bull. Therap., lxxiii. 256; Virchow's Archiv, xli. 
97) the bromide acts very much as upon frogs, inducing progressive 
paralysis, depression of temperature, and death by asphyxia when given 
in small poisonous doses, and great disturbance of the circulation, with 
finally diastolic arrest of the heart, when very freely administered. 

No case of acute poisoning in man with the bromide of potassium 
has been recorded. The nearest approach to a toxic effect I have 
knowledge of was in a medical student at the University of Pennsyl¬ 
vania, who took an ounce by mistake: he reported that the only effects 
were immediate severe pain in the stomach and oesophagus, nausea, a 
little vomiting, great thirst, a feeling of weight in the head, and great 
sleepiness, which lasted for three days. 

The results of the continuous employment of large doses of the 
bromide, howeverydemonsti’ate that it acts upon man as upon the lower 
animals. When it is taken with sufficient freedom to accumulate in the 
system, a conjunction of phenomena known as bromism arises. The 
cerebral symptoms are a sense of mental weakness, heaviness of intel¬ 
lect, failure of memory, partial aphasia, great somnolence, and depres¬ 
sion of spirits. With these there may be decided impairment of the 
sensibility of the mucous membranes and of the skin, so that titillation 
of the fauces may be without effect, and, according to Puche, even heat 
applied to the skin calls forth no complaint: Huette {Memoires de la 
Soc. Biolog., 1850) has seen in some cases absolute anaesthesia of the 
sclerotic conjunctiva. The sexual function is abolished. There is also 
very generally fetid breath, and an eruption of acne, which may indeed 
be very severe. Of course, in any individual case of bromism many 
of these symptoms may be wanting; but when the use of the remedy 
is persisted in, they all at last become developed in an intense degree. 
Professor Edward H. Clarke thus speaks of a case which came under 
his notice: “ The fetid breath becomes nauseous; oedema supervenes on 
congestion of the uvula and fauces; the whispering voice sinks into 


DEPRESSO-MO TORS. 


287 


aphonia; sexual weakness degenerates into impotence; muscular weak¬ 
ness becomes complete paralysis; reflex, general, and special sensations 
disappear; the ears do not hear, nor the eyes see, nor the tongue taste; 
the expression of hebetude becomes first that of imbecility, then that 
of idiocy; hallucinations of sight and sound, with or without mania, 
precede general cerebral indifference, apathy, and paralysis ; the respi¬ 
ration, without the stertor of opium or alcohol, is easy and slow; the 
temperature of the body is lowered; as the bromism becomes more 
profound, the patient lies quiet in bed, unable to move or feel or swal¬ 
low or speak, with dilated and uncontractile pupils, and scarcely any 
change of the color of his skin or face.” Death has been attributed to 
the effect of the continuous use of the bromide in large doses. Thus, 
Dr. Hameau reports (in the Journ. de Med. de Bordeaux ) the case of a 
young woman who took four and a half pounds during the course of 
ten months, and while in a condition of cachexia, with yellowish skin, 
a copper-colored eruption upon the forehead, colic, gastralgia, insomnia, 
etc., suddenly became greatly prostrated, and had delirium with profuse 
sweats, followed by death in four days. Dr. Anton Eigner ( Wiener 
Med. Presse, Nos. 25 to 34, 1886) details the case of a woman who took 
five pounds in less than a year, and while having very pronounced 
symptoms of bromism was seized with delirium and suffered from hal¬ 
lucinations of sight and hearing, saying she was being poisoned, and 
finally died of pneumonia. In neither of these cases can it be con¬ 
sidered probable that the bromide was the direct cause of death. 

Action on Nervous System. —The persistence of voluntary movement 
in the frog after the abolition of reflex actions shows that the influence 
of the drug is not chiefly exerted upon the cerebral centres of motor 
impulse, nor upon those cells of the cord which originate movement, 
but upon either the afferent nerves or those portions of the cord which 
transmit the impulse from these nerves to the cells presiding immedi¬ 
ately over motion. This is confirmed by some experiments of Lewisky, 
in which it was found that previous separation of the cord from the 
cerebrum had no influence upon the action of the bromide. Both he 
and Purser also found that death occurred from small doses before the 
motor-nerve trunks and the muscles had lost their irritability (confirmed 
by Saisson, Schmidt's Jahrb., Bd. cxliii. p. 17). This being so, the ques¬ 
tion arises whether the paralysis be spinal or due to paralysis of the 
peripheral afferent nerves. There is an apparent conflict in the evidence 
upon this point. Eulenberg and Guttmann (loc. cit., p. 103) found that 
when access of the poison was prevented to one or more limbs by tying 
the arteries, reflex actions were abolished in these parts as rapidly as 
in others. Similar results have been obtained by Lewisky, by Roberts 
Bartholow ( Bromides , Providence, 1871), by Purser* (loc. cit., p. 326), 


* From the wording of his memoir, however, it is doubtful whether Purser performed the 
experiment himself. 




288 


GENERAL REMEDIES. 


and by Laborde (loc. cit., p. 434). The latter observer has also found 
that electrical stimulation of a nerve high up will cause violent spasms 
in the muscles directly supplied by it, although it may be unable to ex¬ 
cite the slightest reflex tremor. On the other hand, Damourette and 
Pelvette assert a contrary result. Unfortunately, they do not give the 
details of their experiments. They state, however (p. 247), that if the 
lumbar plexus of vessels be tied before the poisoning, the fore feet lose 
their reflex activity before the hinder. There are two possible methods 
of reconciling their results with those of the other observers. In some 
way the operation may have interfered with the circulation in the lower 
part of the cord, and consequently the poison have reached more freely 
the upper part of it and acted first upon it. Again, if the injection was, 
as is very probable, thrown into the anterior portion of the body, the 
poison may have reached the anterior extremities in so concentrated a 
form as to have acted, as it were, locally upon their nerves and muscles. 
The same observers in another portion of their memoir show that the 
solutions of these salts travel by imbibition; and this and their local 
action seem to me to be the cause of the differences of experimental 
results. It seems well established that cutaneous anaesthesia in greater 
or less degree accompanies the loss of reflex activity; for, as Dr. Purser 
says, a poisoned animal quite able to jump submits to pinching, prick¬ 
ing, burning, etc., without moving. Eulenberg and Guttmann have 
noticed the same thing in some rabbits. Damourette and Pelvette Joe. 
cit., p. 247) have noticed a condition in which electrical stimulation of 
a nerve-trunk produced marked reflex action, although no excitement 
of the skin supplied by the afferent fibres of the nerve was capable of 
doing this, showing that the extremities of the sensitive nerves are 
affected before the trunks. The evidence is, I think, sufficient to prove 
that bromide of potassium affects all parts of the nervous system of 
the lower animals, but that the cerebrum, the motor tract of the cord, 
and the efferent nerves are the last portions to be affected; that the 
most sensitive to its action is the receptive portion of the cord.—that 
which receives and transmits reflex impulses,—and next to this, and 
perhaps almost equally susceptible with it, are the peripheral ends of 
the afferent nerves. 

Upon the cerebrum of the higher animals the bromides undoubtedly 
exert an influence, and the researches of Professor Albertoni (Arch. f. 
Exper. Path. Therap., xv. 256) have thrown much light upon the useful¬ 
ness of the drug in epilepsy. That observer found that when adminis¬ 
tered to dogs the bromide depresses very markedly the power of the 
motor zone of the cerebral cortex to respond to stimuli, and to give 
forth, on decided irritation, epileptic discharges: it was also discovered 
that this action of the bromide was much more decided when there had 
been a prolonged saturation of the system with the drug than after a 
single large or even toxic dose. The intellectual symptoms of bromism 
show that in man the action of the bromide on the cerebral cortex is 


DEPR ESSO- MO TORS. 


289 


more marked than in the lower animals, on account, no doubt, of the 
higher cerebral development. The drug in other respects acts upon 
man as upon lower mammals, lowering the reflex excitability of his 
spinal cord, paralyzing the ends of the peripheral nerves, etc. 

According to the researches of Dr. B. Schulze, there is under the 
influence of the bromide a decided decrease in the elimination of phos¬ 
phorus,—an indication that the protoplasmic molecular changes in the 
nervous system are lessened by the drug (Zeitschrift f. Biol., xix. 301, 
1883). 

Circulation. —It is well established that large toxic doses of the bro¬ 
mide exert a direct paralyzing action on the heart, lessening both the 
force and the frequency of the beat, and finally causing diastolic arrest.* 
Dr. J. G-. Schouten ( Archiv der Heilh., xii. 2, p. 97, 1871; Schmidt's 
Jahrb., Bd. cliv. p. 11) found that during the slow injection of a two- 
per-cent. solution into the vena cava of a rabbit the cardiac systole 
grew slower, the diastolic pauses longer, and finally the heart stood 
still, exhibiting only fibrillary contractions of its walls. The same 
observer is, so far as I know, the only one who has made manometrical 
studies of the action of small doses of the drug. He found that such 
amounts of the bromide administered hypodermically or by the stomach 
always produced increased pulse-frequency with lessened arterial press¬ 
ure. His experiments were, however, not carried far enough to de¬ 
monstrate either how these two changes are brought about, or the rela¬ 
tions of the drug to the vaso-motor nerves. Much has been predicated 
upon the theory which asserts that bromide of potassium causes vaso¬ 
motor spasm. Ho decisive proofs have, however, yet been offered of 
the truth of this favorite dogma. The evidence so far brought forward 
is as follows: Lewisky found that if the toes of two frogs—one poi¬ 
soned, the other not—were cut off, the unpoisoned frog bled much 
more freely than the other. This experiment has been confirmed by 
Dr. Amory: it, however, evidently does not prove the existence of 
vaso-motor spasm, but only that of a lessened activity of the circula¬ 
tion, which may be of cardiac origin. 

According to Damourette and Pelvette ( loc. cit., p. 249), when the 
interdigital membrane of the frog is watched during poisoning, there 
is seen at first very often an exceedingly brief period of increased cir¬ 
culation, but in a very short time the latter becomes much slower. Dr. 
Meuriot (IdEtude de la Belladone , p. 49) asserts that by the aid of the 
microscope this slowing of the circulation can readily be seen to be due 
to a contraction of the capillaries, and especially of the small arteries, 
whose lumen may even be obliterated. Dr. Saisson ( Schmidt's Jahrb., 
Bd. cxliii. p. 17) also asserts that he has witnessed a similar phenomenon 
in the tongue of the frog, and Dr. Hammond and Dr. Amory state that 
they have seen it in the brain of the dog. On the other hand, Dr. 


* For experiments upon the isolated frog’s heart see Med.-Chir. Trans., 1882. 

19 



290 


GENERAL REMEDIES. 


Parser ( loc. cit.') and Dr. F. B. Nunneley ( London Tract., vol. iii. p. 
351) assert that the vessels in the frog’s web are not affected by bromide 
of potassium given hypodermically. 

My own studies of the action of various poisons upon the vessels of 
the frog’s web have yielded such varying and unsatisfactory results as 
to make me hesitate in accepting evidence of this nature unless other¬ 
wise corroborated. In the absence of manometrical studies, I think the 
most that can be fairly claimed is that our present knowledge renders 
it somewhat probable that the salt under consideration is capable of 
producing vaso-motor spasm. The further deduction that the nervous 
symptoms induced are secondary to and produced by this spasm is 
wholly gratuitous, unproved, and improbable. The effect of the bro¬ 
mide when applied locally to the bared nerve demonstrates that it acts 
directly upon nerve-tissue. Further, the absolute anaemia of the blood¬ 
less “salt frog” produces no such nervous symptoms as does even a 
non-toxic dose of the bromide; and the direct experiments of Dr. A. 
Weil ( Reichert's Archiv, 1871, p. 271) have shown that in the frog the 
complete abolition of circulation has no effect upon the spinal marrow 
or upon reflex actions during the first half-hour. The proof is very 
strong that the drug acts directly upon the nervous tissues. 

Temperature. — In warm-blooded animals, toxic doses of bromide 
of potassium lower very decidedly the temperature. There have been 
no calorimetric experiments to determine whether this fall of tempera¬ 
ture is due to a diminished heat-production or an increase in heat-elimi¬ 
nation. The relaxed condition of the vaso-motor system under the influ¬ 
ence of the bromide favors the escape of heat, and it is probable that 
the fall of bodily temperature is due in part or altogether to an exces¬ 
sive loss of heat; especially is this probable since there is a sufficient 
concord in recent researches upon the action of the bromides to indicate 
that they increase rather than diminish tissue-change. 

Dr. Rabuteau ( Gaz. Hebdom., 1869) found that while taking the bro¬ 
mide there was slight lessening in the daily elimination of urea. The ex¬ 
periment was, however, a single one, and the daily dose of the bromide 
was only fifteen grains, an amount so small as to have no determinate in¬ 
fluence. In the American Journal of Medical Science , July, 1868, Dr. H. Bill 
reported the results of an elaborate study of the action of the bromides 
upon elimination. He found that there was a very decided decrease in 
the amount of carbonic acid thrown off from the lungs, but that the 
elimination of urea was not sensibly affected. On the other hand, the 
quantity of urine was usually increased, the coloring-matters invariably 
augmented, and the action on phosphoric acid varied: after smaller 
doses it appeared to be slightly increased. Schulze (Zeitschr. fur Biol., 
vol. xix. p. 301), whose article I have seen only in abstract, in an ap¬ 
parently very careful investigation on his own person, found as the 
result of the ingestion of one hundred and fifty grains of bromide a day 
that the urinary secretion was greatly increased, the phosphorus dimin- 


DEPRESSO-MO TORS. 


291 


ished, the sulphur very much increased, and the nitrogen slightly in¬ 
creased. The experiments of Chittenden and Culbert ( Chem. Stud. 
Laborat. of Yale College ) were also made with great care, and the maxi¬ 
mum dose was one hundred and fifty grains a day. The result was 
diminished excretion of phosphorus, but a pronounced increase of urea. 
In Chitttenden and Culbert’s experiments the bromide of ammonium 
acted like the bromide of potassium, but more powerfully, so far at 
least as the urea was concerned. 

Elimination. —When the blood is charged with the bromide, the salt 
probably escapes with all the secretions. It has been found by Yoisin, 
Amory, Namias, Bill, etc., in the saliva and in the urine, and by Amory 
in the perspiration ( Bost. Med. Surg. Journ., Oct. 1868). In the body of 
a man who died while taking it, M. Namias ( Comptes-Rendus , t. lxx. 
p. 882) found it in all the liquids, as well as in the brain, liver, spinal 
cord, lungs, etc. Elimination takes place to a certain extent through 
the skin, and to some extent through the intestinal mucous membrane 
also. P. Guttmann ( Virchow's Archiv, lxxiv.) has recognized bromine 
in the contents of the acne pustules of bromism. Dr. Bill ( loc. cit., p. 
25) always detected the bromide in marked quantities in the faeces of 
men taking it; and H. Quincke ( Reichert's Archiv , 1868, xxxv. 158) 
found that when forty grains of bromide of sodium were given to 
dogs with intestinal fistula, two and a half hours afterwards the in¬ 
testinal juices were free from the bromide, which reappeared in them 
from three to six hours later. The salt escapes also through the 
kidneys. The rapidity of elimination seems to vary: thus, Amory 
recovered one-half of the amount ingested during the first and one- 
third during the second twenty-four hours, and Mr. Ware (Thesis of 
Dr. H. P. Bowditch, loc. cit.) obtained a little more than half of the 
amount ingested in the urine of the succeeding thirty-two hours, while 
Bill was not able to get more than one-eighteenth of it during the first 
day. Dr. Bill has frequently found the bromide in the urine two weeks 
after the last dose has been exhibited; and Dr. Rabuteau has seen its 
pi’esence persist under similar circumstances for a month. 

It has been claimed (Professor Binz, London Pract., 1874) that the 
bromide of potassium owes its physiological and therapeutic powers 
solely to its base. This is plainly not the case, as the bromide is not 
largely decomposed in the system, and the symptoms caused by it are 
very different from those produced by carbonate of potash: in a later 
publication (Arch. f. Exper. Path. Therap., xiii.) Professor Binz him¬ 
self has shown that bromine vapor produces in frogs effects in many 
respects similar to those caused by the potash salt. At the same time 
it is almost certain that the potash influences the system, and that the 
whole result is produced by a conjoint action of both ingredients of 
the salt. G. Krosz (Arch. f. Exper. Path. Therap ., vi. 43), in three ex¬ 
periments upon man, found decided difference in the results following 
proportionate doses of bromide and chloride of potassium and of bro- 


292 


GENERAL REMEDIES. 


mide of sodium. He attributes the lessening of reflex activity to the 
bromine.* 

Therapeutics. —Bromide of potassium is employed by the thera¬ 
peutist to quiet cerebral excitement when not inflammatory in its nature; 
to lessen over-susceptibility of the spinal centres of reflex action, 
or of the peripheral afferent nerves which lead to these centres; and 
to subdue nervous excitement of the genital system. The contra¬ 
indication to its use is the existence of a high degree of debility or 
exhaustion. 

There are various forms of nervous excitement or unrest, such as 
sometimes follow excessive intellectual toil, anxiety, and other nervous 
strain, or occur during convalescence from acute disorder, in which the 
salt now under consideration is very valuable. The same may be said 
of some forms of hysteria. In some cases of neuralgia it undoubtedly 
affords great relief, but in the majority of cases it fails. It has seemed 
to me useless in neuralgia dependent upon amemia or want of power; 
and my experience agrees with that.of Dr. Anstie, that it is especially 
useful in persons of good nervous power, muscular force, and activity 
of circulation. As a hypnotic, it is employed in wakefulness from 
nervous excitement and in delirium tremens. 

The chief use of the bromide is, however, to lessen reflex activity. 
It is especially in epilepsy that it has attained a well-deserved reputa¬ 
tion, doing far more good than all other remedies combined, sometimes 
effecting cures, more commonly ameliorating the symptoms, but occa¬ 
sionally failing entirely. There is no known method of distinguishing 
before trial with any certainty in what cases it will do good. Trous¬ 
seau ( Clin. Med., Syd. Soc.) and Bartholow (loc. cit.) both assert, how¬ 
ever, that it is least efficient in the mild form of the disorder known as 
the petit mal. The most brilliant results have, as a rule, been obtained 
in cases of not too long duration in which the fits are frequent and 
severe. The governing principle in its use is to try it in every case, 
increasing the dose until a mild degree of bromism is induced, and 
being guided by the results. 

The salt is also often efficacious in other reflex spasmodic neuroses: 
in the vomiting of pregnancy or of uterine diseases; in the convulsions 
of children; and, according to Dr. J. T. Rothrock, in preventing the 
so-called urethral fever induced in very susceptible males by the intro¬ 
duction of the catheter or bougie. The physiological action of the salt 
seemingly indicates that it is of all known remedies the one best suited 
for the treatment of tetanus. Clinical experience certainly accords with 
this conclusion: in the following table are collected thirty-four cases 
of tetanus, nearly all traumatic, in which there were but four deaths. 
Hot less than a half-ounce of the salt should be exhibited in the day, 
and at night chloral should be used as a hypnotic. (See Chloral.) 


* Consult also Steinauer’s paper in Virchow’s Archiv, Bd. lix. 



DEPRESSO-MOTORS. 293 

The table contains all the statistical information I have on the 
subject. Cases not otherwise marked recovered: 


Reporter. 

No. 

Kind. 

Place Reported. 

Remarks. 

Dr. Bachenal . . . 

1 

Traumatic. 

London Lancet, Feb. 1869. 


Dr. Derby .... 

1 

ft 

Boston Med. and Surg. Journal. 

Morphine also used. 

A. Fergusson . . . 

1 

ft 

Edinburgh Med. Journal, July, 1872. 

U. S. Army Med. Department Circular 

Chloral also used. 


1 

«( 





No. 3, Aug. 1871. 


Dr. Panas .... 

1 

<< 

Gazette Hebdomadaire, No. 26, 1872. 

Opium also used. 

Dr. C. L. Bard . . 

1 

11 

New Remedies, Jan. 1873. 

Dr. Bruchou . . . 

1 

tt 

Bulletin Therapeutique, vol. lxxvii. 

Small bleeding and 




p. 8. 

etherization also 
used. 

Robert Brown . . 

1 

« 

Edinburgh Med. and Surg. Journal, 





1869, vol. xiv. p. 992. 


Prof. May Figueira. 

1 

<< 

Bulletin Therapeutique, vol. lxxvii. 





p. 428. 


Ibid. 

1 

Idiopathic. 

Ibid. 


Dr. Panthel.... 

1 

Traumatic. 

Deutsche Klinik, p. 21, 1874. 

Chloral also used. 

Dr. Trenholme . . 

1 

ft 

Canada Med. Record, April, 1875. 

Chloral also used. 

Allen Coutts . . . 

1 

Idiopathic. 

London Practitioner, April, 1871. 

Calabar bean also 



used. 

H. F. Andrews . 

1 

? 

* 1 


H. K. Steel .... 

1 

? 

* ? 

Died. 

G. Derby. 

1 

? 

* i 

Took nearly 12 oz. 





of the salt. 

Dr. Bakewell . . . 

1 

? 

* ? 


Dr. Hancock . . . 

1 

? 

* ? 

Died.-f- 30 grains of 





the bromide every 
four hours, with 
20 minims of the 
tincture of bella¬ 
donna. 

R. Southey .... 

1 

Idiopathic. 

Trans. Lond. Clin. Soc., x. 146. 

Died. Bromide not 



usedfreely enough 
to test its value. 



A. Cartaz. 

1 

Traumatic. 

Le Progres Med., 1875, 370. 


Levis. 

1 

Traumatic. 

Phila. Med. Times, v. 167. 

Chloral also used. 

H. Van Buren ' . . 

1 

Traumatic. 

Chicago Med. Journ., Feb. 1880. 

Chloral, Calabar 




bean, and opium 
also used. 


I. W. Lankard . . 

2 

Traumatic. 

Virginia Med. Monthly, 1880, 698. 

Chloral and opium 




also used. 

Dr. Salter .... 

1 

Traumatic. 

London Practitioner, Feb. 1882. 

Chloral also used. 

Dr. Bourgeons. . . 

I 

Traumatic. 

Paris Thesis, 1880, No. 260 (Landouard). 

Died. 

Dr. Guichard . . . 

1 

Traumatic. 

tt it it tt 


Dr. Regnault . . . 

1 

? 

tt ft tt tt 


Dr. Brenugat . . . 

3 

Traumatic. 

tt tt tt tt 


Dr. Regnault . . . 

1 

Traumatic. 

tt tt tt tt 


Dr. Dein. 

1 

Traumatic. 

tt tt tt tt 


Dr. Gaudon. . . . 

1 

? 

ft ft tt ft 



In strychnine-poisoning , Dr. Saisson has demonstrated the value of 
the bromide by experiments on animals, and Dr. Chas. B. Gillespie 
(Amer. Journ. Med. Sci., Oct. 1870) and Dr. C. L. Bard ( Phila. Med. 
Times, June, 1871) have each reported recovery under its use, without 
vomiting, after the ingestion of three grains of the alkaloid. 

In nervous excitement connected with the genital function , bromide 
of potassium is often of great value. When there is actual inflamma¬ 
tory disease, as in gonorrhoea , the drug frequently fails to effect the 
desired end. If, however, there be no organic lesion of the organs 
or of their nerve-centres, the continued dose will usually succeed to a 


* All the cases marked with an asterisk are taken from Dr. Roemer’s paper (£t. Louis 
Med. and Surg. Journal, 1873). I believe they were all traumatic. 

f Since the belladonna probably did as much harm as the bromide did good, this case 
ought to be excluded. 






















294 


GENERAL REMEDIES. 


greater or less extent. I have found the remedy effective in cases of 
semi-impotence from over-irritability of the organs causing emission 
too soon during attempted sexual congress. There is abundant evi¬ 
dence as to its value in nymphomania. As an adjuvant to other physical 
and moral measures of relief, the salt may be used with satisfaction 
in men suffering from masturbation. In nervous symptoms occurring 
at the time of the menopause or complicating uterine disease, and in 
the peculiar train of morbid phenomena arising from the forced sup¬ 
pression of the sexual function in vigorous individuals of either sex to 
whom circumstances have denied marriage, the bromides have almost 
a “unique power.” 

Dr. Ch. Bernard ( The Clinic, Sept. 1874; from Bulletin Gen. de 
Therap .) affirms that bromide of potassium in doses of from twenty 
to forty-five grains a day removes with marvellous quickness malarial 
enlargements of the spleen. 

Administration.— I have known half an ounce of the bromide to 
be taken at once without inducing any serious symptoms; and in severe 
acute cases, as in tetanus and strychnine-poisoning, it is perfectly safe 
to administer two-drachm doses at short intervals, as the case may re¬ 
quire. Almost all the indications for the use of the bromide are best met 
by the so-called continuous dose,— i.e., by the administration of so much 
in the twenty-four hours until an effect is induced. Thus, in epilepsy, 
half a drachm may be given four times a day, to be increased to one 
drachm (half an ounce a day) if necessary: although as little of the 
remedy as will suffice to prevent the recurrence of the fit must be used, 
yet any amount necessary to do this should be given, unless bromism 
be produced before the paroxysms are arrested. The remedy must be 
exhibited, in a solution freely diluted, after meals. In some cases it 
causes diarrhoea, which may generally be checked with small doses of 
opium. It is essential in epilepsy and other chronic disorders to per¬ 
sist in the continuous administration of the bromide, it may be for 
years; and it is remarkable how rapidly the symptoms of long-continued 
bromism subside upon the withdrawal of the drug. 

AMMONII BROMIDUM—BROMIDE OF AMMONIUM. U.S. 

According to the U.S. Pharmacopoeia, this salt should be prepared 
by the precipitation of the freshly-made solution of the bromide of 
iron by water of ammonia, the desired salt remaining in solution. It 
may be obtained in colorless crystals, but generally occurs in a granular 
powder, which becomes yellowish on exposure. It has a saline, pun¬ 
gent taste, is readily soluble in water, sparingly so in alcohol. When 
mixed with mucilage of starch, if chlorine-water be added it becomes 
yellowish brown; a blue tint would indicate the presence of iodine. 

Physiological Action.— The physiological action of the bromide 
of ammonium has not as yet been fully investigated ; but our present 
knowledge indicates that while in many points it resembles that of the 


DEPRESSO-MO TORS. 


295 


corresponding salt of potassium, in others it differs essentially from the 
latter. According to Dr. N. Bistroff ( Reichert's Archiv , 1868, p. 723), 
when two decigrammes are administered to a frog, a period of quietude 
and lessened irritability is induced, which after fifteen or twenty min¬ 
utes gives place to violent tetanic convulsion. Later, all excitability 
is lost, so that even burning calls forth no recognition; the frog lies 
in whatever position it is placed in, the spasms become more violent, 
and death ensues. Similar phenomena have been witnessed by both 
Bistroff and Amory ( Bromide of Potassium and Bromide of Ammo¬ 
nium , Boston, 1872) in the rabbit and the guinea-pig, although in one 
of Dr. Amory’s experiments the guinea-pig died without convulsions 
having been noted. The curious abolition of reflex action and of sen¬ 
sibility consentaneously with the occurrence of violent convulsions was 
noted frequently, and death seems always to have resulted from as¬ 
phyxia. In the experience of Dr. Bistroff, moderate non-fatal doses 
produced only weakness and uncertain movements in the rabbit. 

Bromide of ammonium appears to exert very little influence upon 
the peripheral motor apparatus. Amory has seen the nerves retain 
their power of conduction after having been placed in a “ strong solu¬ 
tion and, according to Dr. Bistroff, muscles retain their irritability 
after soaking five minutes’ in a ten-per-cent, solution. According to 
the latter observer, the heart always continued beating after death from 
the drug, and the heart removed from the batrachian and laid in a ten- 
per-cent. solution did not in any degree lose its normal activity. Even 
a twenty-per-cent, solution dropped upon the bared heart produced only 
a momentary arrest of the ventricular systole. On the other hand, Dr. 
Purser asserts that the heart is soon arrested in diastole in poisoning 
by this salt, and that the nerves and muscles also lose their irritability 
sooner than after poisoning by bromide of potassium. 

The subject certainly needs further investigation; but it seems to 
me most probable that bromide of ammonium exerts less influence upon 
the muscles than does bromide of potassium, but that in other respects 
their actions are very similar. The experiments of Amory indicate 
that the ammonium salt affects temperature and acts on the capillaries 
in the same way as that of potassium, and that it is also eliminated in 
a similar manner. The experiments of Dr. Bistroff show that in the 
cat, at least, bromide of ammonium has no especial influence, as has 
been asserted, upon the superior laryngeal nerves. 

Therapeutics.— Bromide of ammonium has been employed by 
practitioners for exactly the same purposes as the corresponding potas¬ 
sium salt, but certainly has not made its way into general use. Dr. 
Brown-Sequard commends highly the combination of it and its sister- 
salt in epilepsy as being much superior to either of them alone. lie 
gives sixty grains of the potassium with thirty of the ammonium salt, 
and claims especially immunity from the disagreeable symptoms of 
bromism. On the other hand, Echeverria ( On Epilepsy , p. 316) asserts 


296 


GENERAL REMEDIES. 


that the combination is in no wise superior to bromide of potassium. 
Professor Clark, however ( loc. cit ., p. 106), from an experience in other 
than epileptic neuroses, is inclined to coincide with Dr. Brown-Sequard. 
The disease in which bromide of ammonium has been most used is 
pertussis. Dr. J. M. Da Costa commends it highly in acute rheumatism 
{Pennsylvania Hasp. Rep., vol. ii.): a drachm to a drachm and a half 
of it was given, well diluted, in the twenty-four hours. 

Bromide of Sodium, U.S., closely resembles in appearance bromide 
of potassium, and has been supposed by Yoisin to have closely similar 
physiological and therapeutic properties. On the other hand, M. J. V. 
Laborde states (Robin’s Journal, 1868, p. 560) that in double the toxic 
dose of bromide of potassium he has found that it does not produce 
any characteristic symptoms in the frog, the guinea-pig, or the dog, and 
leaves the animal perfectly healthy. 

By clinicians the drug has been used to a considerable extent. Dr. 
Meredith Clymer {New York Med. World, October, 1871) claims that it 
will arrest epilepsy without producing the unpleasant cerebral symp¬ 
toms of bromism. He gives twenty grains three times a day. Profes¬ 
sor Hammond {New York Medical Journal , Dec. 1871) asserts that in 
epilepsy it is in no wise superior to the potassium salt, but claims that 
its hypnotic power is much greater. M. E. Decaisne, as the result of 
the trial of the drug in twenty-seven cases ( epilepsy , chorea, hysteria ), 
asserts that its action is the same as that of the potassium salt, except 
that instead of causing diarrhoea it constipates ( Comptes-Rendus, Ho. 17, 
1870). Notwithstanding this testimony, my own experience is in accord 
with the physiological teachings, that bromide of sodium, although not 
free from therapeutic value, is not equal to bromide of potassium in 
subduing nervous excitation, and is in no wise superior to it. 

Bromide of Lithium, U.S., was, I believe, first employed in medi¬ 
cine by Dr. Gibb {British Association for the Advancement of Science , 
1864), who recommended it as gently tonic and sometimes diuretic. 
He used it in very small doses. Attention was first called to its em¬ 
ployment in nervous affections by Dr. S. Weir Mitchell, who stated 
{Amer. Journ. Med. Sci., Oct. 1870), as the result of his experience, that 
when administered to the amount of half a drachm to one drachm 
daily, it acts in some cases of epilepsy after bromide of potassium has 
failed, and that it is generally efficient in about one-half the dose of 
that salt; also that its hypnotic action is much more decided. Professor 
Clark {loc. cit., p. Ill) confirms these observations.* 

I 

Bromide of Nickel.— Bromide of nickel is a yellowish-green pow- 


* For bromides of zinc and cadmium, see Le Progres Mid., 1877; for hgdrobromic ether, 
Robin’s Journal, 1877, Le Progrls Med., 1877. 



DEPRESSO-MO TORS. 


297 


der, of a sharp, burning taste, yielding with water a grass-green solu¬ 
tion, which was introduced by Dr. J. M. Da Costa as a remedy for 
epilepsy and allied disorders, and whose value has been confirmed by 
Dr. Leaman (. Med. News, April 18, 1885). Its physiological action has 
been investigated by Dr. H. A. Hare ( Therap . Gaz., ii. 297). He finds 
that in the frog it paralyzes the spinal cord, the motor and the sensory 
nerves, and the muscles. Brought in contact with the isolated frog’s 
heart, it destroys at once the contractile power of the muscle. In the 
mammal in sufficient dose it causes death by diastolic arrest of the 
heart. Smaller doses produce fall of the arterial pressure by depres¬ 
sion of the vaso-motor centre and of the heart. The pulse is primarily 
slowed,—probably, as Dr. Hare believes, by a direct influence upon the 
intra-cardiac ganglia or muscle-fibre. 

According to Leaman, bromide of nickel is well borne by the 
stomach, if given well diluted as an effervescing powder, made by 
mixing the salt with bicarbonate of sodium and tartaric acid, moisten¬ 
ing with alcohol, passing the moist powder through a sieve, and drying 
in a warm closet. He estimates that ten grains of the nickel salt are 
equal to thirty grains of bromide of potassium, and gives the dose as 
from five to ten grains. 

Hydrobromic Acid.—A solution of the gaseous compound of bro¬ 
mine and hydrogen in water was first employed as a therapeutic agent 
by Dr. Wade ( Peninsular Journ. Med., Feb. 1875). Dr. E. T. Reichert 
(. Bost. Med. and Surg. Journ., civ. 505) found that its action upon the 
nervous system and the circulation is almost identical with that of 
bromide of potassium; but its influence upon the brain-cortex was not 
studied. Moderate doses caused some temporary elevation of the blood- 
pressure, which Dr. Reichert attributes—without, as I think, sufficient 
evidence—to vaso-motor spasm of peripheral origin. Large doses were 
directly paralyzant to the heart and to a less extent to the voluntary 
muscles. Reflex action is suspended by the acid in the frog, and all 
portions of the spinal cord and nerves are depressed by the poison; 
but Dr. Reichert presents experimental facts which indicate that the 
sensory portions of the cord and the sensory nerves are affected before 
the motor system by hydrobromic acid as they are by the bromides. 
A long series of trials which I made with hydrobromic acid in the 
Epileptic Wards of the Philadelphia Hospital determined that the 
officinal acid in equivalent doses acts very much as does the bromide 
of potassium, but is distinctly more irritant to the stomach, and less 
apt to produce an eruption of acne or muscular depression. It may 
be used alone in the treatment of epilepsy, but the combination of it 
with the bromide has seemed to me the best form of administration: 
the large dose required, when it is given by itself, in most cases irritates 
the stomach too much. Under all circumstances it must be well diluted. 
The officinal dilute hydrobromic acid (Acidum Hydrobromicum Dilutum. 


298 


GENERAL REMEDIES. 


U.S.) represents in each drachm nine grains of bromide of potassium, 
and may be given in one-half- to one-fluidounce doses in a tumblerful 
of sweetened water. 

Bromal Hydrate.— This substance, which has been looked upon 
until recently merely as a chemical curiosity, is formed by the action 
of bromine upon alcohol, the alcohol being first converted into alde¬ 
hyde by losing two atoms of hydrogen, and the bromine then replacing 
the remaining three atoms of hydrogen. The physiological etfects 
of bromal hydrate have been especially investigated by Drs. John G. 
JVlcKendrick (. Edinb. Med. Journ., July, 1874), E. Steinauer ( Virchow's 
Archiv , Bd. lix. p. 65), Rabuteau (Gaz. Hebdom., t. xliii. p. 681), and Br. 
Chrostowski ( Hoffmann und Schwalbe's Jahresb ., 1881, 197). After 
large doses death occurs in a very few minutes, with contraction of the 
pupil, dyspnoea, and convulsions. After smaller amounts (three grains 
in a rabbit of three or four pounds’ weight) the symptoms are succes¬ 
sively restlessness, dilatation of superficial vessels, contraction of the 
pupil gradually increasing to a maximum, enormous secretion from 
the buccal and nasal mucous membranes, greatly increased rapidity of 
respirations, deepening paralysis, coma, lessened frequency of respira¬ 
tions, anaesthesia, convulsions, and death from failure of respiration. 
Chrostowski finds that the drug acts directly upon the heart-muscle 
and excito-motor centres, and much more powerfully than does chloral. 
The peripheral vaso-motor apparatus was apparently not affected by it. 
What knowledge we have of its physiological action does not indicate 
remedial value, and clinical experience with it is still wanting. 

AMYL NITRIS—NITRITE OP AMYL. U.S. 

Nitrite of amyl was discovered by the French chemist Balard (An- 
nales de Chimie et de Phys., xii.) in 1844, and the attention of physi¬ 
ologists was called to it in 1859 by Guthrie; but it was not until 1865 
that Dr. Richardson, of London, introduced it to the notice of the pro¬ 
fession. It is a yellowish, oily, very volatile liquid, of a very pene¬ 
trating, persistent, fruity odor. It is prepared by the action of nitric 
acid on amylic alcohol, or, as it is commonly called, fusel oil. 

Physiological Action.— Nitrite of amyl can be absorbed by any 
surface except the skin, but, on account of its volatility, has hitherto 
been used in man chiefly by inhalation. Owing to the physical prop¬ 
erty just mentioned, its action is extraordinarily quick and very tran¬ 
sient, it being absorbed and eliminated with great rapidity. 

The most prominent symptoms induced when it is inhaled by a man 
in moderate quantities are a sense of great fulness and distention of the 
head, amounting at last to severe pain, and accompanied by intense 
flushing of the face, a deep, labored respiration, and an exceedingly 
rapid, violent action of the heart. The succession of these phenomena 
is so rapid that often they seem to be simultaneous; but it is said that 


DEPRESSO-MO TORS. 


299 


the cardiac disturbance is sometimes very distinctly manifest before 
the other symptoms. It has been noticed by Peck and confirmed by 
Ladendorf that objects look yellow to a person fully under the influ¬ 
ence of the drug. After poisonous doses the symptoms have been 
great pallor, dilatation of pupils, excessive muscular relaxation, slow, 
scarcely perceptible pulse, and irregular respiration ( Amer. Journ. Pharm., 
1881, 137). In a case reported by Dr. Strahan (Journ. Ment. Sci., xxx. 
252) a hypodermic injection of ten minims of a ten-per-cent, solution 
of nitrite of amyl was followed in a minute and a half by two succes¬ 
sive furious epileptic convulsions, each preceded by arrest of respiration 
and of the heart’s action. 

In the lower animals the first stage of the action is like that just 
described in man. After this the breathing becomes violently hurried 
and panting, progressive muscular weakness and diminution of reflex 
activity ensue, and finally death from failure of respiration,—sensation 
and consciousness being preserved almost to the last. 

A very peculiar symptom is that a long time before death the arterial 
blood becomes of almost the same color as the venous blood. Con¬ 
vulsions are sometimes present; but in my experience more often the 
animal is exceedingly quiet throughout the poisoning. 

Elaborate experimental studies of the action of nitrite of amyl 
upon the circulation in animals have been made by Dr. T. Lauder 
Brunton (Journ. of Anat. and Physiol., vol. v.,— Berichte der Math.-Phys. 
Classe d. k. sacks. Gesellschaft f. Wissensch., 1869), by myself (Amer. 
Journ. Aled. Sci., July, 1871), and by Dr. Amez-Droz (Archives de Phy¬ 
siol. Norm, et Pathol., Sept. 1873, p. 467). The results are so uniform 
and in such accord that they must be accepted as proved facts. 

Circulation .— It has been found by all three observers just mentioned 
that, although the pulse is very much increased in frequency sometimes 
from the very beginning, the arterial pressure is diminished, and finally 
is reduced almost to zero, and that the fall of pressure occurs equally 
after section of the vagi as at other times. As the number of heart¬ 
beats in the uninjured animal is increased rather than diminished, 
while the strength of the individual beat is not perceptibly lessened, 
it is evident that, at least in the early stages of the poisoning, the 
diminution of arterial tension is not cardiac in origin, but must be due 
to dilatation of the capillaries. This conclusion is confirmed by an 
experiment of Brunton, who found that if the descending aorta was 
tied up high, no perceptible fall of pressure was produced by the inha¬ 
lation of the amyl salt until very late in the poisoning, when the heart 
itself was acted upon by the drug; also by the fact noted by Dr. Amez- 
Droz and by Gaspy ( Virchow's Archiv, lxxv. 310), that the vessels of 
the rabbit’s ear and of the frog’s web can be seen to dilate when the 
salt is inhaled.* That dilatation of the vessels takes place in man, as 


* A noteworthy fact asserted by Amez-Droz is that after a long period of dilatation the 
vessels contract again, whether the inhalation be continued or not. I think the explanation 



300 


GENERAL REMEDIES. 


well as in the lower animals, is shown by the flushing of the face, as 
well as by the enlargement of the retinal vessels, noted by Dr. Chas. 
Aldridge ( West Riding Lunatic Rep., vol. i. p. 187). 

An interesting question which here arises is, whether the dilatation is 
centric, due to an action on the vaso-motor nerve-centres, or peripheral, 
due to a direct action on the muscular coat of the arterioles. I be¬ 
lieve it must be peripheral, and not centric, in its origin, since both in 
my own experiments and in those of Brunton it occurred after the 
arterioles had been separated from the vaso-motor centres by division 
of the cord. This fact appears to prove that the fall of arterial press¬ 
ure is due to a direct paralyzing action of the drug upon the coats of 
the arterioles,—a conclusion confirmed by our knowledge of the local 
action of the nitrite upon muscular tissue. 

Bernheim, however, asserts that this cannot be so, and that the 
dilatation must be solely due to an action upon the vaso-motor centres, 
because he found that galvanization of the cervical sympathetic still 
caused contractions in the vessels of the ear of a rabbit to which nitrite 
of amyl had been given. As pointed out by Pick ( Centralbl. f. Med. 
TFisse/is., No. 55, 1873), Bernheim’s experiment does not warrant his 
conclusion. It only shows that the muscle-fibres in the walls of the 
vessels are not so completely paralyzed as to be unable to respond to 
very powei-ful stimuli. Dr. W. Pilehne ( Pfluger's Archiv, Bd. ix. p. 478 ) 
dissents from the view here taken; but it seems to me that the fall of 
arterial pressure after paralysis by section of the vaso-motor nerves 
absolutely proves that the drug acts locally upon the arterial coats. It 
is, however, very probable from the general sedative effect of the drug 
upon the motor centres that it acts also upon the vaso-motor centres; 
and when the local flushings caused by small doses of the poison are 
borne in mind, this probability is greatly enhanced. Filehne affirms 
that when to animals, whose lungs were exposed, inhalations of the VJ 
nitrite were given, the change of color was not nearly so great as in 
the ears, and that if the sympathetic had been destroyed in the neck 
in a rabbit, and the nitrite of amyl exhibited, the vessels on the un¬ 
wounded side actually became larger than those of the opposite ear. 

The answer to these results is, that opening the chest must derange 
most profoundly the pneumonic circulation, and that all observations 
upon the comparative size of vessels are very apt to be mere guess¬ 
work when the change is slight. Moreover, in Schuller’s experiments 
(Berlin. Klin. Wochenschrift, No. 25, 1874), after destruction of the cer¬ 
vical sympathetic in a rabbit, inhalations of the nitrite produced still 
further dilatation of the vessels of the ear. In conclusion, it seems to 

of this is simply that, owing to the volatility of the nitrite, it soon all escapes from the dossil 
of lint on which it is placed for inhalation; an explanation strongly confirmed by a statement 
of Dr. Amez-Droz, that in these cases a new inhalation was followed by dilatation as before. 
Amez-Droz says only the arterioles dilate, but Gaspy found that both arterioles and veins were 
affected. 



DEPRESSO-MO TORS. 


301 


me established that nitrite of amyl does act locally on the coats of the 
arterioles, although it may at the same time influence the vaso-motor 
centres. 

In man the pulse-rate is enormously increased by nitrite of amyl. 
In animals the amount of the increase varies, but in the higher groups 
the rule appears to be increase of the pulse-rate, which is especially 
decided in the dog. Filehne ( Pfluger's Archiv, Bd. ix. p. 490) has by a 
single very ingenious experiment apparently shown that the accelera¬ 
tion is due to a depressing influence upon the inhibitory centres. He 
divided the par vagum in a rabbit, employed an electric current to the 
severed nerves of sufficient strength to bring the pulse-rate to normal, 
and found that the amyl salt was powerless to affect the rapidity of 
the cardiac action. Certain experiments performed by Mayer and 
Friedrich (Arch. f. Exp. Path. u. Pharm., v. 63) confirm that of Filehne. 
It is known that sudden asphyxia slows the pulse by exciting the in¬ 
hibitory centre. Mayer and Friedrich found that this action is pre¬ 
vented by the inhalation of the amyl salt. Then, again, they found 
that when by compression of the arteries the blood was prevented 
from going to the head, the nitrite did not increase the rapidity of the 
pulse, and also determined that the reflex inhibitory slowing of the 
heart by irritation of a sensitive nerve is prevented by nitrite of amyl. 
Further, in dogs with a powerful cardiac inhibitory apparatus the 
primary influence of the nitrite is more marked than it is in rabbits, 
whose pneumogastrics are very feeble. The sudden, thumping action 
of the heart so prominent in man when the nitrite is inhaled is there¬ 
fore probably, at least in part, due to depression of the inhibitory 
apparatus. There is, however, as pointed out by Dr. Beichert (IV. Y. 
Med. Journ ., July, 1881), much reason for believing that in small doses 
the nitrite acts primarily as a stimulant to the heart. Lauder Brunton 
long ago discovered that if the aorta be compressed so as to eliminate 
in great part the influence of the vaso-motor system, the nitrite causes 
rise in the arterial pressure; and it is perfectly possible for an excessive 
heart-action to be more than neutralized, so far as the arterial pressure 
is concerned, by a vaso-motor depression, so that the immediate fall of 
pressure caused in the normal animal by the nitrite is not proof that 
the heart may not be stimulated. The question could be readily settled 
experimentally by studying the action of the drug in minute quanti¬ 
ties upon the cut-out frog’s heart; at present the physiological evidence 
only justifies the belief that it is probable that nitrite of amyl in small 
amount primarily stimulates the heart. It is very certain that finally, 
if the dose be large enough, the heart-muscle will be depressed, and it 
may be paralyzed, by a direct action of the nitrite. 

Nervous System .—I have found (loc. cit.), as the result of numerous 
experiments made in the ordinary methods, that the diminution of 
reflex activity and of voluntary motion which undoubtedly occurs in 
toxaemia from the agent now under consideration is chiefly spinal in its 


302 


GENERAL REMEDIES. 


origin; since after death the nerves and muscles preserve, though in an 
impaired condition, their functional power. On the motor centres 
of the cord the nitrite acts as a direct and powerful depressant, at the 
same time that it exerts a similar but much less pronounced influence on 
the nerves and muscles, decreasing, but not destroying, their functional 
life. The diminution of reflex activity is never preceded by a stage of 
functional excitement. In some animals convulsions do occur, espe¬ 
cially when the drug is administered by inhalation; but they are in all 
probability cerebral, not spinal, and due to the asphyxiating influence 
of the poison. Over the sensory nerves and centres nitrite of amyl 
has but little power. They are among the last portions of the body to 
be affected, sensation being intact until near death: so that the drug is 
in no sense an antesthetic. Mayer and Friedrich assert that at first 
nitrite of amyl increases the rapidity and depth of the respiration by 
stimulating the respiratory centres. Whether this be or be not correct, 
it is certain that later the respiratory centres are greatly depressed, 
the breathing becoming both slow and shallow, and death finally occurs 
from paralytic asphyxia of centric origin. 

Urine. — Elimination. —Dr. F. A. Hoffmann found ( Reichert’s Archiv, 
1872, p. 747) that in the rabbit a hypodermic injection of 0.111 to 0.113 
gramme of the drug is enough to cause diabetes. If twice this amount 
of the amyl salt is used, the sugar becomes very abundant in the urine, 
and continues to be present for from twelve to thirty hours. Consen¬ 
taneously with the elimination of sugar there is a great increase in the 
amount of the urine. In a patient under my care, to whom the salt 
was given very freely, at no time could sugar be detected in the urine : 
so that glycosuria is probably induced only by toxic doses. The nitrite 
is probably oxidized in the system, at least in part, as F. Rohrmann 
(Zeitschr. f. Physiolog. Chemie , v. 233) has found that when nitrite of 
potassium is administered to the lower animals the nitrate appears in 
the urine. 

Local Action. —Nitrite of amyl causes a progressive loss of func¬ 
tional power in every highly-organized tissue with which it comes in 
contact. Nerve-centres, peripheral nerves, muscles of organic and 
voluntary life, all succumb to it alike. If the contact be not continued 
too long, the tissue may recover even after a total suppression of its 
function,—a proof that the poison exerts no destructive chemical or 
devitalizing influence upon the tissues, such as that of sulphuric acid 
or veratria. 

Temperature. —Nitrite of amyl, in whatever way exhibited, if given 
in sufficient amount, reduces most remarkably animal temperature. I 
have seen a pigeon perfectly conscious although its temperature had 
been brought down by this agent some 13° F. This influence is as 
marked in fever as in the normal condition of the animal, and is inde¬ 
pendent of the nerve-centres, occurring after section of the cord, and 
even after death in those cases in which post-mortem rise or continu- 


DEPRESSO-MO TORS. 


303 


ance of high temperature normally takes place. I have also experi¬ 
mentally determined that it is associated with diminished excretion of 
carbonic acid. It must therefore be due to a dix-ect arrest or check of 
tissue-changes or oxidation within, or without, the blood. The mouth- 
temperature in man is certainly sometimes elevated by the inhala¬ 
tion of nitrite of amyl, but the rise is a very temporary one. W. A. 
Manassein and N. Sassezki (St. Petersb. Med. Wochenschr ., 1879, iv. 392) 
found, in a number of studies upon normal and fevex-ed men, that while 
the periphei*al temperature was at first increased the rectal temperature 
was always reduced, and after a time even the surface of the body grew 
coolei*. The maximum reduction was reached in one to one and a half 
hours, and in a case of fever amounted to 3° C. 

The vapoi’s of the nitrite have a very marked influence over oxida¬ 
tion outside of the body, as is shown by many facts, of which it is only 
necessary hei'e to cite the extinguishment of glowing phosphorus by 
a few drops of the amyl salt diffused through the jar. It cannot be 
doubted that within the economy the same thing oceui-s. If, however, 
the arrest of oxidation were complete, instant death from suffocation 
would result. The true explanation of the symptoms evidently lies in 
diminution, not destruction, of oxidation. 

When an animal inhales nitrite of amyl, the arterial and venous 
blood soon become of a nearly uniform hue, which resembles somewhat 
that of normal venous blood, but is quite distinct from it, having a 
chocolate tint. Moreover, this chocolate-colored blood does not assume 
the arterial hue when shaken with the aii*. Dr. Arthur Gamgee (Philos. 
Trans., 1868, p. 589) discovered that as the chocolate color is assumed 
by the blood the two spectrum bands of the oxyhsemoglobin disappear 
and are replaced by new bands, nearly, but not exactly, in the place of 
those of acid hxematin. If ammonia be added to the chocolate blood, 
the color changes back to a blood-red again, and simultaneously the 
spectrum lines x*egain their noi*mal position. If a inducing agent, such 
as sulphide of ammonium, be added to the chocolate blood, it is able to 
deoxidize the oxyhremoglobin, but, before doing so, evidently removes 
it from union with the nitrite, since the new bands disappear and those 
of oxyhxemoglobin reappear in the spectrum before the lines of the re¬ 
duced hemoglobin manifest themselves. Dr. Gamgee also found that 
the nitrite of amyl blood had lost its power of absorbing oxygen, or of 
yielding oxygen to the air-pump, and that carbonic oxide gas added to 
the blood did not expel oxygen from it. Having thus determined that 
a new compound is formed in the blood by the nitrite, Dr. Gamgee 
finally succeeded in obtaining it in a crystalline form. As he always 
upon analysis found the nitrite in this compound, he considered it to be 
a nitrite-oxyhremoglobin. Recent researches have, however, shown 
that the spectrum of this new compound is identical with that of 
Methremoglobin of Iloppe-Seyler (Zeitschr. f. Physiol. Chem., Bd. ii., Bd. 
iii. 54), so that the identity of the two substances is very pi*obable. 


304 


GENERAL REMEDIES. 


These facts do not seem to me to prove that nitrite of amyl entering 
into the blood-vessels at once overpowers the haemoglobin of the blood- 
corpuscles and checks all oxidation. As already stated, the experiments 
of Dr. Gamgee showed conclusively that this new compound yields up 
its oxygen to reducing agents. Further, the doctor found that when 
the nitrite blood was brought into contact with prepared guaiacum-paper 
it still ozonized it, though not so actively as normal. It is evident that 
the blood-corpuscles retain to a greater or less degree their power of 
yielding up ozone to bodies desiring it, and are capable of exerting at 
least this portion of their respiratory function : further, when this ozone 
is given up and the oxyhremoglobin changed into haemoglobin, so far as 
our present knowledge goes, the haemoglobin must absorb more oxygen 
before it can reunite with the nitrite. Evidently, then, absorption of 
oxygen must take place ; evidently the blood-corpuscles must perform 
their respiratory function; but evidently also they are greatly crippled 
and impaired in the rapidity and ease of its performance. Haemic res¬ 
piration is, in other words, greatly interfered with, but not abolished. 

The accord of the results of this chemical investigation with those 
arrived at by a purely physiological study of the drug is very striking 
and very beautiful, both teaching the same thing,—lessened but not 
absolutely arrested oxidation. 

Having ascertained the existence of diminished oxidation in poison¬ 
ing by nitrite of amyl, the temptation is very strong to attribute all the 
symptoms produced by it to this arrest. I do not, however, think that 
this post hoc propter hoc argument is justifiable, for the following rea¬ 
sons. In the first place, nitrate of potassium and other nitrates, accord¬ 
ing to Dr. Gamgee, act in the same manner upon the blood, yet the 
symptoms caused by them are very different from those caused by 
nitrite of amyl. In the second place, when arrest of oxidation is caused 
by deprivation of oxygen (see article on Nitrous Oxide) the symptoms 
are very different, the brain and consciousness being always affected 
before the centres of reflex action, whereas under the influence of 
nitrite of amjd the contrary occurs. In the third place, other sub¬ 
stances, such as toxic doses of alcohol, check oxidation, but do not 
cause the same symptoms as does the drug under consideration. The 
obvious inference seems to me to be that nitrite of amyl acts directly 
upon the nerve-centres, independently of its influence on the blood. 

Summary .—The dominant physiological action of nitrite of amyl is 
upon the spinal cord and the circulation. Under its influence arterial 
pressure falls from paralysis of the blood-vessels, chiefly as the result 
of a direct action upon the muscles in their walls. At the same time 
the heart is, directly or indirectly, enormously stimulated, the number 
and force of its contractions being increased, this period of stimu¬ 
lation after moderate doses gradually subsiding into the normal state, 
but after toxic doses passing into one of cardiac paralysis, with a final 
arrest in diastole, which is due to a direct action upon the heart- 


DEPRESSO-MO TORS. 


305 


muscle or contained ganglia. Paralysis of motion and loss of reflex 
activity, prominent phenomena of advanced poisoning, are due to a 
direct action upon the motor side of the spinal cord. Death results 
finally from paralysis of the respiratory centres. By a direct action 
upon the red blood-corpuscles the haemoglobin is converted into a new 
compound, met-haemoglobin. The fall of the bodily temperature is 
probably the result of lessened oxidation. Locally applied in concen¬ 
trated form, nitrite of amyl paralyzes all higher tissues. 

Therapeutics.— The results of the clinical use of nitrite of amyl 
are in accord with what has been said of its physiological properties. 
Its administration in angina pectoris appears to have been first sug¬ 
gested to Dr. Brunton ( Lond . Clin. Soc. Rep., vol. iii.; Lancet , July 
27, 1867) by the sphygmographic tracings giving evidence of arterial 
spasm in a case of that disorder. As the pathology of these cases of 
heart-pang is not definitely made out, it seems useless to speculate 
how the nitrite acts in many cases;* but there is abundant evidence 
of its value in relieving almost instantly agony which has resisted all 
other treatment. This appears also true whether valvular disease or 
merely functional disorder exists. In cases of advanced fatty degener¬ 
ation or of very great dilatation of the heart, I think its use would be 
attended with some danger, owing to its effect upon the heart-muscle. 
Dr. Foster [Brit. Med. Journ., 1874, i. 77) has found the drug of great 
service in a case of cardiac disease in which there was aortic insuffi¬ 
ciency with excessive hypertrophy and severe frontal headache. 

Its physiological action would indicate that it should be of service 
in all cases of spasm of the capillaries, of the bronchial tubes, and of 
the muscular system generally. Accordingly, Dr. Oskar Berger ( Allgem. 
Medicin. Central-Zeitung, May, 1871) and others have used it with very 
good effect in migraine with evident capillary contraction. In asthma 
my own experience of several cases coincides with that of various 
physicians, that it will often instantly arrest the paroxysm,f especially 
in those instances in which there are no secondary lesions, such as 
emphysema and dilated heart. 

The convulsion of epilepsy is, according to the present theory, due 
to a vaso-motor spasm at the base of the brain, to correct which the 
amyl salt would seem to be indicated, as it also is by the mere existence 
of the convulsion. In advanced stages of the paroxysm it must, how¬ 
ever, be used with caution, on account of the obscuring of its early 
effects by the symptoms of the disease. In the status epilepticus , when 
there is an almost indefinite repetition of the fits, the remedy may be 
of great use in stopping them. When there is a notable interval in 
ordinary epilepsy between the aura and the convulsion, the latter can 


* For a case of failure, see Lancet, August, 1867. 

f For remarkable cases, see British Medical Journal, Sept. 30, 1873 j also Butler’s Com¬ 
pendium, part xiii., Jan. 1874. 


20 



306 


GENERAL REMEDIES. 


usually, if not always, be entirely prevented (Dr. S. Weir Mitchell, 
Phila. Med. Times , vol. v. p. 553) : the patient should carry a small vial 
containing a few drops of the drug, and inhale it at once whenever the 
aura is felt. 

Dr. Mitchell also calls attention to the value of the nitrite as an aid in 
diagnosing those occasional cases of nervous disorder in which petit-mal 
is simulated by attacks really due to passing congestion of the nerve- 
centres. He asserts that in these cases nitrite of amyl instead of arrest¬ 
ing the paroxysm increases its intensity. Dr. Wm. F. Jenks has found 
the nitrite efficient in arresting puerperal convulsions , but dangerous on 
account of producing uterine relaxation and post-partum hemorrhage, 
—a result to be expected from the known physiological action of the 
drug ( Phila. Med. Times, 1872, vol. ii. p. 404). In tetanus nitrite of 
amyl would seem to be indicated as a spinal sedative, and as control¬ 
ling excessive tissue-changes and consequent rise of temperature. It 
has been used, so far as I know, in only three cases ( Lancet , 1871; 
Phila. Med. Times , vol. v.), all of which recovered, two with the amyl 
salt alone and the other with it and chloral. In nervous dysmenorrhcea 
the remedy was first used successfully by Dr. Fuckel; it has been 
highly commended by Dr. Mary Putnam-Jacobi (JY. Y. Med. Pec., Jan. 
1875) and by Dr. P. Peck ( Deuts. Arch. Klin. Med., xvii. 143). Two to 
six drops should be given when the pain comes on, and repeated pro re 
nata. In cholera nitrite of amyl has been tried without, that I can per¬ 
ceive, even a good theoretical reason, and has not seemed to be of ser¬ 
vice {Pond. Med. Pec., vol. i.). Dr. V. Urbantschitsch has employed 
it with various results in various irregular cases of vaso-motor disturb¬ 
ances, in intermittent coryza, migraine, etc. ( Wiener Med. Presse, 1877). 
I have seen it used in a number of cases of intermittent fever, with the 
invariable result of putting an end to the chill and of not affecting the 
hot sta^e. 

o 

The increased cardiac action produced by inhalation of the nitrite 
has led to its employment as a cardiac stimulant, and there is now much 
clinical evidence in favor of its employment in cases of sudden heart- 
failure. It has even been given with asserted excellent results in “ fatty 
heart" (Osgood, Amer. Journ. Med. Sci., 1874, xx. 58) and in syncope 
from hemorrhage (Madden, Lond. Practitioner, xii., 1874).* In cardiac 
failure during anaesthesia it has been employed in a number of cases. 
The peculiar rapidity of its action makes it especially valuable in emer¬ 
gencies, and, though further experimentation is necessary before we 
can understand its use in anaesthesia, clinical experience is sufficient to 
warrant its cautious administration. Further, by direct experiment 
Dr. Reichert has found (Phila. Med. Times, May 21, 1880) that when 
by the ethylen bichloride the blood-pressure and pulse-wave in the dog 


* Consult also Phila. Med. Times, iv.; Psychol, and Med.-Surg. Journ., Feb. 1875; 
London Lancet, May, 1875; Med. Times and Gaz., Dec. 1874; Brit. Med. Journ., 1877. 



DEPRESSO-MO TORS. 


307 


have been depressed almost to zero they are immediately markedly 
increased by the amyl salt. 

The physiological action of the remedy would very strongly indicate 
it as an antidote in sP'yc/mme-poisoning. No case of its use for this pur¬ 
pose in man has come to my knowledge, but the experiments of Dr. St. 
Clair Gray on rabbits ( Glasgow Med. Journ ., 1871, p. 188) yielded very 
favorable results. In two rabbits to each of which ten drops of the 
nitrite and half a grain of strychnine were given together subcutane¬ 
ously, no decided symptoms whatever were induced; while one-quarter 
grain of the alkaloid alone frequently caused death in a single convul¬ 
sion. These results have been confirmed by Dr. Hobart A. Hare ( Boston 
Med. and Surg. Journ., Nov. 1884). During the paroxysm of cramp 
asphyxia it was found necessary to give the nitrite hypodermically, on 
account of the lack of respiratory movement. 

Administration.— As already stated, the method of administration 
usually employed hitherto is inhalation, from one to three or five drops 
being placed on a handkerchief and held near the mouth or nose, the 
handkerchief being removed so soon as a sense of fulness of the head 
is experienced. I have given it by the mouth, dropped upon a lump 
of sugar and taken instantly in doses of two or three drops. There is 
not at present sufficient evidence to enable us to decide as to the maxi¬ 
mum amount of the drug which it is safe to give. In a case of cholera 
( Lond. Med. Record , Oct. 1873), Dr. D. B. Smith exhibited hypoder¬ 
mically two drachms in the course of an hour and thirty-six minutes 
without inducing any serious symptoms, and a dose of a dessertspoonful 
has been recovered from, emetics being given ( Amer. Journ. Pharm., 1881, 
137). Used with care, the nitrite, although a very rapidly-acting and 
powerful agent, seems to be safe, since I have never seen either in man 
or in the lower animals any sudden or unexpected action,—any in¬ 
fluence out of proportion to the amount given. It must be borne in 
mind that the symptoms generally increase in intensity for a minute or 
two after the withdrawal of the drug.* 

Nitrite op Potassium f has been very carefully and intelligently 
studied by Dr. E. T. Eeichert {Amer. Journ. Med. Sci., lxxx. 180). Doses 
of six to ten grains in man sufficed to raise the pulse to 110 or 120, with 
flushing of the face and intracranial throbbing; the symptoms usually 
began in twenty minutes and lasted several hours, and were in no case 
disagreeably severe. Eructations of a phosphorus-like taste were nearly 
always present. Ten to fifteen grains have produced complete muscular 
relaxation, livid lips, headache, etc., lasting three hours ( Lancet , 1883, 


* For a case in which an epileptic convulsion followed a hypodermic injection of one 
minim of the nitrite, see Journ. Ment. Sci., xxx. 252. It is doubtful whether the convulsion 
was caused by the nitrite. 

f For a paper on the theory of the action of the nitrite of sodium by Professor Binz, see 
Arch.f. Exper. Path. u. Pharm., xiii. 138. 



308 


GENERAL REMEDIES. 


ii. 766). In a very elaborate series of experiments upon animals, Dr. 
Keichert found that the effects of nitrite of potassium and of nitrite of 
sodium upon the blood, heart, and nerve-centres are indistinguishable 
from those of nitrite of amyl except in being much less rapid and more 
permanent. In cases of angina pectoris the duration of the influence 
of these nitrites makes them especially desirable, and they will prob¬ 
ably in practice be found superior to the amyl salt. Twenty grains of 
the commercial nitrite of sodium have been given without serious effect, 
but of a pure article, either of the sodium or the potassium nitrite, the 
dose is three grains; five grains have often produced serious symptoms 
(see London Lancet , 1883, ii. 945). At present a pure article is com¬ 
monly kept in good drug-stores. The dose may be repeated every two 
hours cautiously. 

Nitroglycerin is the most powerful of the nitrites. The symp¬ 
toms which it causes in man are giddiness, constriction, or other ab¬ 
normal sensations in the head, often amounting to severe headache, 
choking in the throat, sometimes nausea, and rapid cardiac action, with 
lessened arterial pressure. After toxic doses there is great failure of 
the heart’s action. A single drop of a one-per-cent, alcoholic solution 
has produced insensibility, and in the case of Mr. Field, who took two 
drops, loss of consciousness and of the pulse at the wrist were complete 
(see Brit. Med. Journ., 1880, i. 406). Dr. J. Noer ( Therap. Gaz., 1887, 
459) attributed the following symptoms in a woman to the use of ten- 
drop doses of the alcoholic solution of nitroglycerin. The pulse was 
slow, intermittent, and very irregular, the pupils dilated, the urine 
scanty and containing considerable pigment. There was also pain in 
the region of the heart, intense headache, sense of constriction around 
the forehead, and great weakness of the stomach. Drs. Lauder Brunton 
and Tait ( St. Barthol. Hosp. Bep., xii. 140) have found that upon blood- 
coloration, arterial pressure, nerve-centres, and muscles nitroglycerin 
acts very much as does nitrite of amyl. This similarity of action 
between nitroglycerin and the nitrites has been recently confirmed 
by Dr. Murrell and Dr. Matthew Hay ( Lond. Practitioner , xxx. 422), 
also by A. Ilenocque ( Comptes-Bendus Soc. de Biolog ., 1883, v. 669), 
and is remarkable, as nitroglycerin may he regarded as nitrate of 
glyceryl. It has been shown, however, by Hay, that during its alka¬ 
line decomposition it yields nascent nitrous acid, and it can scarcely be 
questioned that this acid is developed in the blood and acts upon the 
system. 

The effect of nitroglycerin is certainly more prolonged than that 
of nitrite of amyl. According to Professor Korczynski, the maximum 
effect of a dose in man is reached in from three to fifteen minutes, 
while all effects disappear in three-quarters of an hour ( Schmidt's Jahrb., 
cxciii. 132). Within the last few years nitroglycerin has been used 
quite largely in the London hospitals, with asserted excellent results, 


DEPRESSO-MO TORS. 


309 


in neuralgia and in angina 'pectoris. The practice has found imitators 
on both continents. The reports are almost universally favorable in 
regard to the action of the drug In cardiac failure, and in asthma, 
uraemia, and puerperal eclampsia, and other affections in which experi¬ 
ence has shown that nitrite of amyl is of value. 

Dr. Trusse witsch [St. Petersb. Med. Wochenschr., No. 1,1887) states that 
he has obtained excellent results from the use of nitroglycerin in neu¬ 
ralgia, headache, dizziness, and other irregular nervous symptoms, and 
even in general failure of health in persons whose weak, small pulses 
and peculiar pallor marked the habitual fulness of the venous system. 
He is in the habit of commencing with half of the ordinary dose in 
these cases, increasing it if the results are favorable. 

Nitroglycerin is kept in the drug-stores in one-per-cent, alcoholic 
solution, the dose of which may be set down as a half-drop, increased 
to two or three drops if necessary. It is said that this solution is not 
explosive, but that, unless care be exercised in manipulating it, head¬ 
ache and other unpleasant symptoms are apt to be produced. Mr. 
Martindale has shown that nitroglycerin is soluble in cacao butter, and 
it has been proposed to administer it in the form of chocolate lozenges. 

According to the researches of Dr. Richardson [Brit, and For. Med.- 
Chirurg. Rev., July, 1867) nitrite of ethyl acts very similarly to nitrite 
of amyl; and it can scarcely be doubted that all of the nitrites depend 
for their physiological activity upon nitrous acid and have similar 
physiological properties. 

Valerianate of Amyl has been introduced to the medical profession 
by Dr. W. F. Wade [Brit. Med. Journ., i., 1874), who appears to consider 
its therapeutic properties about the same as those of valerianic acid. 
He makes a compound spirit by adding one part of the valerianate to 
nineteen of alcohol, and to each ounce half a minim of acetate of amyl. 
Of this he gives eight drops in an ounce of water. The preparation is 
no doubt an active one, but probably possesses other properties than 
those of valerianic acid. According to Gr. Bruel [L' Ether Amyl-valeri- 
anique ), valerianate of amyl is capable of dissolving three times as much 
cholesterin as is chloroform, and may be employed with the greatest 
advantage for the purposes of dissolving biliary calculi. He also asserts 
that it is a valuable hypnotic and antispasmodic, useful in such spasmodic 
diseases as asthma, hysteria, hepatic, renal, and intestinal colic, etc. 

LOBELIA. U.S. 

The leaves and tops of the indigenous herb Lobelia inflata. The 
dried plant has a slight irritating odor and a taste at first scarcely per¬ 
ceptible, afterwards burning, acrid, and attended with a flow of saliva. 
The active principle is Lobeline, a yellowish liquid alkaloid, discovered 


310 


GENERAL REMEDIES. 


by Professor Procter, of this city. Lobelic acid, a fixed and a volatile 
oil, gum, chlorophyl, etc., are also present in the drug. 

Physiological Action. —The symptoms produced by large doses of 
lobelia in man are nausea, soon followed by violent vomiting, accompa¬ 
nied with intense prostration, as is shown by feeble pulse, cold sweats, 
pale skin, and great muscular relaxation. Purging may or may not 
occur. Numerous cases of fatal poisoning by it have been recorded. 
The symptoms are those above mentioned, intensified; in some cases 
vomiting does not occur, and it is especially under these circumstances 
that fatal effects have been noted. Burning in the fauces and oesopha¬ 
gus, and epigastric distress, in addition to the intense prostration, border¬ 
ing upon collapse and finally merging into complete collapse, wfith coma, 
stupor, muscular tremblings, and in some cases convulsions, precede the 
fatal termination. 

Our knowledge of the physiological action of lobelia is very imper¬ 
fect: what we have is chiefly derived from the researches of Dr. I. Ott 
( Bost. Med. Surg. Journ., 1875, Phila. Med. Times, vi.). He found that in 
the frog it produced a gradually increasing palsy, ending in death from 
paralysis of respiration. After death the motor nerves were found in¬ 
sensitive, although the muscles were still irritable. He did not deter¬ 
mine whether the spinal cord also suffers, or whether the paralysis is 
solely due to the palsy of the motor nerve. In the rabbit, the symp¬ 
toms produced by the alkaloid were slowing of the respiration, progres¬ 
sive palsy, fall of the bodily temperature, convulsive seizures, and death 
from asphyxia. The alteration of the blood-pressure consisted in an 
immediate fall, succeeded in some cases by a very decided rise of press¬ 
ure, followed in turn by a fall. The rise of pressure appears to me to 
have been produced not by the direct action of the poison, but by the 
asphyxia induced by it. In large doses lobelia seems to paralyze the 
vaso-motor centres; at least galvanization of a sensitive nerve in the 
poisoned animal failed to induce any rise of pressure. Such doses were 
also shown to have a paralytic action upon the peripheral vagi. Dr. 
Afanasieff appears to have arrived at results similar to those obtained 
by Dr. Ott. Unfortunately, the memoir is published in the Hussian 
language (abstracted Land. Med. Pec., Aug. 16, 1886). It is not stated 
whether the peculiar alterations of arterial pressure occurred in curarized 
animals; but small doses caused in the curarized animal persistent rise 
in the arterial pressure. In frogs small doses at first increased the 
cardiac contractions. If the dose were sufficient, the first period of 
stimulation was followed by fall of pressure, with periodically recurring 
diastolic arrests, and irregular contractions ending in final diastolic 
arrest with distention. 

Toxicology.— The symptoms of lobelia-poisoning have been suffi¬ 
ciently described. The treatment should consist in washing out the 
stomach with plenteous draughts of a warm solution of tannic acid, 
in the free exhibition of opium and of alcoholic and ammoniacal stimu- 


DEPRESSO-MO TORS. 


311 


lants, and in the use of external stimulation by dry heat, frictions, mus¬ 
tard, etc., precisely as in poisoning from veratrum viride. 

Therapeutics. —Lobelia has been used as an emetic; but its depress¬ 
ing effects are so severe as to forbid such employment of it. It has 
also been employed to relax spasm in various affections, as in pertussis, 
tetanus, epilepsy, chorea, convulsions, but has been superseded by more 
efficient and less dangerous remedies. It is often useful in spasmodic 
asthma or in acute bronchitis with bronchial spasm, and appears to be 
expectorant as well as antispasmodic. An infusion (£i to Oj) has been 
strongly recommended as a local application in the eczema produced by 
the rhus toxicodendron, or “ poison-vine.” The powder is very rarely 
used; the dose as an emetic is twenty or thirty grains. The dose 
of the vinegar (Acetum Lobelice —1 to 10, U.S.) is twenty to thirty 
minims; of the tincture ( Tinctura Lobelice. —1 to 5, U.S.), as an expec¬ 
torant, ten to twenty minims,—in the paroxysm of asthma, f3i to f 3ii 
every half-hour until nausea is induced. The dose of the fluid extract 
( Extractum Lobelice Fluidum, U.S.) is, as an expectorant, one to five 
minims; as an emetic, fifteen minims. 

GELSEMIUM. U.S. 

The root of G-elsemium sempervirens, the yellow or Carolina jessa 
mine , a beautiful climbing plant of the Atlantic Southern United States, 
distinguished by its large, axillary, very fragrant, clustered blossoms 
and perennial dark-green leaves. The very light, fibrous, dirty-yellow- 
ish root has a bitterish taste, and contains an alkaloid, Gelsemine, in com 
bination with Gelseminic Acid , both discovered by Professor Wormley. 

Physiological Action. —There is a wide range of susceptibility 
in man to the influence of gelsemium, some individuals being pro¬ 
foundly influenced by a dose which has no perceptible effect upon 
another person. After the smallest active dose (five to fifteen minims 
of the fluid extract), the only symptom is languor; with it may be a 
little lowering of the force and frequency of the pulse. When a some¬ 
what larger amount is ingested, to the languor are added dizziness and 
disturbance of vision, with, in some cases, a pain over the brows. Ringer 
and Murrell state that the pupil is contracted, but this is probably an 
inconstant result. After toxic doses of the poison the muscular weak¬ 
ness is extreme, and in several cases ( Bost . Med. and Surg. Journ., 1869, 
iii. 185; 1879, ci. 18) the flexors of the arms have been especially af¬ 
fected. The disturbance of sight is now very marked; double vision, 
or partial or even complete blindness, may exist; the pupil is widely 
dilated and immovable; the external rectus muscle is weakened, some¬ 
times sufficiently to produce a marked internal squint; the eyelid 
droops, and is raised with difficulty or falls in paralytic ptosis. If the 
patient is able to walk at all, the gait is staggering; the jaw drops, 
articulation fails; the general sensibility is much impaired; respira¬ 
tion slow and labored; the pulse feeble and thready; the skin bathed 


312 


GENERAL REMEDIES. 


in a cold sweat; the bodily temperature greatly lowered. Sometimes 
drowsiness is felt after moderate doses of the poison, but consciousness 
may be preserved in the midst of very severe symptoms, although in all 
the fatal cases I have met with it was lost before death. The drug acts 
very promptly, symptoms usually appearing in about twenty minutes 
after its ingestion, and beginning to subside in two or three hours. 

Gelsemium produces in the lower animals symptoms similar to those 
which it causes in man, with the exception that convulsions are very 
generally developed. They are not always present, but they have been 
observed in the frog, pigeon, cat, rabbit, and dog. The loss of voluntary 
power precedes the convulsions, and in the careful experiments of Einger 
and Murrell ( Lancet , 1876, i. 83) upon frogs it was found that the cord 
was rapidly exhausted by repeated irritations, so that convulsions could 
not at once be induced. Professor Bartholow states that in the rabbit, 
cat, and pigeon the convulsive movements are backward, sometimes 
amounting to complete somersaults. The close study of the action of 
gelsemium is best made by taking up the various systems in rotation. 

Nervous and Muscular Systems. —The retention of consciousness until 
very late in the poisoning, both in man and in the lower animals, shows 
that the drug has very little power over the higher cerebrum, although 
the drowsiness and the final loss of consciousness prove that it is not 
entirely devoid of such influence. The two most prominent symptoms 
caused by the drug are the convulsion and the paralysis. The first 
question to be determined is whether the convulsion is cerebral, spinal, 
or peripheral. That it is not cerebral is proved by its occurrence in the 
pithed frog (Einger and Murrell, Lancet , 1876, i. 83), and below the 
point of section in mammals with divided spinal cord (Taylor, Richm. 
and Louisv. Med. Journ., 1875, p. 606); that it is not peripheral is 
proved by its taking place in the posterior extremities when the lower 
aorta is tied before the poisoning (Einger and Murrell). The cause of 
the convulsion at present remains inexplicable. The theory of di¬ 
minished resistance (see p. 209) can hardly be received, because in the 
careful experiments of Dr. Ott ( Phila ;. Med. Times , vol. vii. p. 289) a 
condition of exaggerated reflex activity was proved to precede the 
convulsive state. Einger and Murrell conceive that there are present 
in gelsemium two active and antagonistic substances, one a tetanizant, 
the other a paralyzant; but in their own experiments, and in those of 
Dr. Ott, gelsemine believed to be pure produced convulsions. Never¬ 
theless, it is notable that Ott found the acid so much stronger in con¬ 
vulsive action than the alkaloid as to suggest the truth of Einger and 
Murrell’s supposition. 

The paralysis in poisoning by gelsemine is evidently spinal in its 
origin, as its development is not affected by tying an artery before 
poisoning so as to protect a limb (Bartholow, Practitioner , vol. v., p. 
203; Einger and Murrell, Lancet , 1875, ii. 908), and as the afferent and 
motor nerves and muscles preserve their functional activity until death 


DEPRESSO-MO TORS. 


313 


(Ott, Bartholow,* Ringer and Murrell). It is a matter of some im¬ 
portance, in explaining the spinal action of the drug, to determine its 
influence upon the different portions of the cord. Dr. Bartholow says 
that “ it acts also on the sensory portion of the cord, producing at last, 
complete anaesthesia; but this effect in warm-blooded animals and in 
man is toxic only, and follows the paralysis of the motor functions.” 
This may be correct, but, so far as I know, has not been experimentally 
proved. 

Respiration. —Gelsemium usually kills by a paralysis of respiration. 
According to the researches of Burdon Sanderson and of Ringer and 
Murrell ( Lancet , 1876, i. 490, 560), immediately after the ingestion the 
extent of the respiration, but not its rate, is increased; very shortly, 
however, both rate and depth enter a condition of progressive pals}' - 
ending in death. The respiratory changes are the product of a direct 
action upon the respiratory centres, being uninfluenced by previous 
section of the vagi. 

Circulation. —The action of moderate doses of gelsemium upon the 
circulation is not very marked. That in toxic amounts it depresses 
both the pulse-rate and pressure is abundantly shown by the symptoms 
erf poisoning in man, and by Dr. Ott’s experiments upon animals ( Phila. 
Med. Times , v. 691). As the pulse-rate and pressure were reduced 
in these experiments after previous section of all the cardiac nerves 
and of the spinal cord, it is evident that the poison exerts a direct in¬ 
fluence upon the heart. How far the vaso-motor centres are influenced 
by the drug has not been accurately determined. 

Eye. —The influence of gelsemium upon the organ of vision is very 
decided. Ringer and Murrell affirm that decided non-toxic doses of 
the drug cause contraction of the pupil. However this may be, marked 
dilatation of the pupil is a very constant symptom in the poisoning. It 
has also been discovered by Ringer and Murrell, aud confirmed by Mr. 
John Tweedy ( Lancet , 1877, i. 833), that the local application of gel- 
semine to the eye produces violent mydriasis, with paralysis of accom¬ 
modation. This indicates very strongly that the dilatation is produced 
in poisoning by the drug through an influence exerted upon the periph¬ 
eral nerve ending in the eye. The palsy of the external rectus and the 
ptosis indicate that such action is paralytic, so that it is a probable con¬ 
clusion that peripheral oculo-motor paralysis is the cause of the dila¬ 
tation of the pupil. The falling of the jaw and the loss of the power 
of articulation indicate that all the motor nerves of the head are acted 
upon by the poison. 

Therapeutics.— Gelsemium was originally employed as an arterial 
sedative and febrifuge in the malarial fevers of the South, and subse- 

% 

* Dr. Roberts Bartholow affirms ( Practitioner , v. 203), “This experiment indicates 
that gelsemium destroys the excitability of the sensory nerve before the motor;’' but his 
conclusion seems hardly warranted by his premises, and in his treatise on therapeutics he 
distinctly avows the centric origin of the paralysis. 



314 


GENERAL REMEDIES. 


quently in other sthenic fevers. It appears in some way to depress the 
bodily temperature, but certainly possesses no controlling influence over 
the arterial system at all comparable to that of veratrum viride and 
aconite. Dr. Bartholow commends it highly, as in pneumonia and pleu- 
ritis; its influence for good in these disorders would seem, however, to 
be chiefly associated with its power of lessening the rapidity of respi¬ 
ration and increasing the tendency to perspiration. It does not appear 
probable that any advantage to be derived from it will counterbalance 
the dangers attending its employment in the large doses required. In 
asthma, spasmodic laryngitis, whooping-cough , and nervous cough, in which 
it is also recommended by Professor Bartholow, its employment seems 
more plausible, as in these cases there is a distinct spasmodic element. 
The testimony to its value is most marked in cases of trigeminal, ovarian, 
and other neuralgias. How it does good in these disorders is as obscure 
as is the nature of the neuralgias, and in my hands it has usually failed. 
The marked effect of the drug upon the facial nerves would appear to 
indicate its employment in facial neuralgias, and especially in facial 
spasmodic affections. In acute mania the drug may be employed in full 
doses as a calmative. 

Mr. Tweedy has drawn attention to the local use of gelsemium 
(Lancet, 1877, i. 832) by the oculist as a substitute for atropine, claim¬ 
ing that it may be employed with equal surety as a paralyzant of ac¬ 
commodation and dilator of the pupil, and that it possesses the very 
great advantage of its influence going off in a few hours. Thoroughly to 
paralyze accommodation, however, it must be used freely; as he states, 
“ To insure paralysis of accommodation within three hours, a solution 
of at least eight grains [gelsemine] to the ounce must be used every 
fifteen minutes for the first hour, and every half-hour afterwards.” 
Employed in this way, I should think there would be some danger of 
general poisoning by absorption. 

Toxicology. — Dr. I. Ott ( Phila. Med. Times, v. 693) has collected 
six cases of fatal poisoning; a teaspoonful of the fluid extract being 
the smallest amount that has caused death in the adult. Professor 
Wormley believes that his chemical examinations have shown that in 
one fatal case the fluid extract ingested could not have contained more 
than one-sixth of a grain of the alkaloid. 

The treatment of gelsemium-poisoning should be conducted on 
general principles. Our present knowledge does not indicate that mor¬ 
phine and gelsemium are physiological antagonists, but Dr. Geo. S. 
Courtright asserts that they have such relation, and details a case in 
which recovery occurred after the ingestion of from one to two tea- 
spoonfuls of the tincture, one and one-half grains of morphine having 
been given hypodermically and one grain by the mouth ( Cincinnati 
Lancet and Observer, 1876, p. 963). 

Administration. —The dose of the fluid extract (.Extractum Gelsemii 
Fluidum, U.S.) is five minims every two hours until constitutional effects 


DEPRESSO-MO TORS. 


315 


are produced; of the tincture (Tinctura Gelsemii —1 to 6.6, U.S.), ten to 
twenty minims. 

TABACUM—TOBACCO. U.S. 

Tobacco in its various forms is so familiar an article of every-day life 
that I shall not enter upon any description of it. Its sole active prin¬ 
ciple is an alkaloid, Nicotine , it having been proved that the alleged alka¬ 
loid Nicotianin has no existence. Nicotine , when pure, is a colorless, 
transparent, volatile liquid, of a strong tobacco-like odor and a persistent 
burning taste. It is freely soluble in water, which it absorbs readily 
and largely from the air. Its salts are crystallizable with difficulty. 

Physiological Action. —Upon those persons who are not habitu¬ 
ated to its use, tobacco acts as a very powerful depressant, producing 
horrible nausea and vomiting, with giddiness and a feeling of intense 
wretchedness and weakness. If the amount taken has been large, to 
these symptoms are added burning pain in the stomach, purging, free 
urination, extreme giddiness passing into delirium, a rapid, running, 
and finally imperceptible pulse, cramps in the limbs, absolute loss of 
muscular strength, a cold, clammy skin, and finally complete collapse, 
terminating in death. 

Nicotine produces, when taken in minute quantities, symptoms suffi¬ 
ciently similar to those just detailed. Thus, Schroff (quoted by Stille 
and by Krocker) found that in doses of from one-thirty-second to one- 
sixteenth of a grain it caused an intense burning in the fauces, oesopha¬ 
gus, and stomach, which diffused itself as a sense of heat all through 
the body, and was followed by giddiness, nausea, and some vomiting, 
with a rapid, feeble pulse, diarrhoea, intense muscular weakness, labori¬ 
ous respirations, icy extremities, partial loss of consciousness, and other 
indications of impending collapse. Keil ( Journ . /. Pharmacodynam., Bd. 
ii. p. 203) took one-seventh of a grain of the alkaloid, with the produc¬ 
tion of burning in the throat and stomach, headache, a feeling of heat 
in the head, increase of pulse-rate sixteen beats, muscular weakness, 
and a sense of oppressed respiration. In one or two instances, violent 
muscular tremblings have come on shortly after the ingestion of the 
poison, and ended in general clonic convulsions. In large amounts 
nicotine acts with lightning-like rapidity. Thus, in a case of suicide, in 
which an unknown amount was taken ( Taylor's Medical Jurisprudence , 
vol. i. p. 393), the man dropped instantly to the floor insensible, gave 
a deep sigh, and was dead in about three minutes. 

When a minute drop (gtt. -£-$) of nicotine is administered to a frog, 
the first evidences of local irritation are succeeded in a few seconds by 
tetanic cramps, in which the front legs are laid forcibly along the side 
of the trunk, and the feet bent over the back. This position is said by 
Krocker to be characteristic of nicotine- or conine-poisoning, and to 
be due to the extensor muscles being more powerfully contracted than 
the flexors. When very minute doses are administered, according to 


316 


GENERAL REMEDIES. 


Yulpian, this general tetanus is replaced by muscular tremblings and 
irregular convulsions. After a short time the motor excitement in 
either case is succeeded by complete muscular relaxation, which, if the 
dose has been toxic, soon passes into general paralysis, and finally 
death by failure of respiration, the heart continuing to beat after 
breathing has ceased. The symptoms which the poison produces in 
mammalia are exactly parallel with those which it causes in the ba- 
trachian. The evidences of the pain produced by the intense local irri¬ 
tation caused by the poison are soon succeeded, after a small dose, by 
muscular tremblings and irregular voluntary movements, during which 
the animal often falls through weakness, and which rapidly give way 
to violent tetanic and clonic convulsions; to these succeeds an intense 
calm, in which voluntary movement is largely but not altogether abol¬ 
ished. In the first part of this stage external irritation still produces 
convulsions, but later it is without influence. The urine and faeces are 
usually voided, and sometimes vomiting occurs. The pupils, at first 
narrowly contracted, now (Krocker) dilate slightly, but not to the nor¬ 
mal point. The breathing, which at first was rapid and shallow, be¬ 
comes distant and fuller, the peripheral capillaries are relaxed and full 
of blood, and finally paralysis deepens into death. After death the 
venous system is usually found engorged. The physiological action 
of the alkaloid can best be studied in detail by taking up the various 
systems separately. 

Nervous and Muscular Systems. —Upon the cerebrum nicotine probably 
exerts very little direct influence. The convulsions* are certainly of 
spinal or peripheral origin, since they occur, according to the experi¬ 
ments of Krocker, in frogs whose cerebrum has been extirpated. That 
they are not peripheral is pi’oved by the experiments of Vulpian 
( Comptes-Rendus de la Soc. de Biol., 1859, p. 151), who found that cut¬ 
ting off all the arterial communication between the hind legs of the 
frog and its trunk did not affect the development of the convulsions, 
when the animal was poisoned with nicotia. This has been confirmed 
by Krocker, who also found that if the nerve-trunk of a limb be di¬ 
vided the convulsions cease in that limb. The convulsions are, there¬ 
fore, spinal, and the first stage of nicotine-poisoning is one of spinal 
excitement. The question here naturally arises, Is the paralysis of the 
second stage due to spinal depression ? There is not yet sufficient evi¬ 
dence to warrant a positive decision as to bow far the cord is involved 
in the paresis, but Krocker is probably correct in believing that it is at 
least to some degree affected, since he found that tying the arteries of 
a limb so as to preclude the poison from reaching the nerves did not pre¬ 
vent the limb from lying limp and powerless during the paralytic stage. 

The action of the poison upon the peripheral nerves has been defi- 


* P. Uspensky has found (Reichert's Archiv, 1868, p. 525) that these convulsions are not 
influenced by artificial respiration. 



DEPRESSO-MO TORS. 


317 


nitely settled by the experiments of Yulpian, of Rosenthal ( Centralbl. 
f. Med. Wissen., 1863, p. 738), of Krocker, and of Hare, all of whom have 
found that the functional activity of the motor or efferent nerves is 
more or less completely abolished by the poison. By tying the artery 
low down in one leg of a frog, so as to protect the peripheral endings, 
applying the galvanic currents some distance above this point, and 
comparing the results with those obtained by galvanizing unprotected 
nerves, Krocker determined that the peripheral endings were paralyzed 
sooner than the nerve-trunks, although the trunks themselves were 
finally affected. The peripheral nerve-endings appear to be at first 
excited, as Yulpian and Krocker have found that muscular tremblings 
are not prevented by section of the supplying nerve, and that they even 
occur in the curarized frog. These fibrillary contractions also occurred 
when the alkaloid was injected into a leg whose connections with the 
trunk had been cut off by a tight general ligature. According to Yul¬ 
pian and Rosenthal, the sensory or afferent nerves retain their activity 
to the last; but Lautenbach believes that they are affected ( Phila . 
Med. Times , May, 1877). Upon the voluntary muscles all observers are 
in accord in asserting that nicotine exerts no influence. 

Circulation. —When nicotine is added to freshly-drawn blood, the latter 
assumes a peculiar dark hue, and the microscope shows that the red 
corpuscles rapidly disintegrate. In nicotine-poisoning the blood is, how¬ 
ever, not perceptibly affected. The amount of the alkaloid necessary to 
take life is exceedingly small, and although the death by asphyxia causes 
the vital fluid to be everywhere dark, yet most observers state that 
under the microscope the corpuscles are normal. According to Krocker, 
the dark blood assumes an arterial hue when shaken with the air. This 
is confirmed by Dr. H. A. Hare ( Fiske Fund Prize Piss., Phila., 1885), 
who, however, found that the spectrum of the hemoglobin is altered, 
so that it is probable that the red corpuscles are somewhat affected by 
the poison: indeed, Hare affirms that after very large doses changes in 
the corpuscles can be detected by the microscope. 

The action of the drug upon the heart is very complicated, and has 
not yet been well determined. Upon the cardiac muscle the poison 
appears to have very little influence; after death from it the heart 
is found pulsating, and Dr. W. T. Benham ( West Riding Lunatic Asylum 
Rep., vol. iv., 1874) found that the pure alkaloid painted over the cut¬ 
out heart of a rabbit or injected into its cavities did not arrest its 
movements : indeed, on the contrary, the heart which had ceased action 
was stimulated to renewed effort by the application of the drug. Ac¬ 
cording to Traube ( Allgem. Med. Central-Zeitung, 1862) and to Hare, 
when a minute quantity of nicotine is injected into the jugular vein of 
a curarized animal, artificial respiration being maintained, the pulse 
and arterial pressure at once sink to half their original position, but in 
about twenty seconds rise rapidly, the arterial pressure attaining a 
maximum of about two and a half times its normal grade, the pulse 


318 


GENERAL REMEDIES. 


also exceeding its original rate. This period of increased tension lasts 
about a minute, after which the arterial pressure commences to fall, as 
does later the pulse-rate also, and finally both sink much below their 
normal position. After many minutes the pulse generally increases its 
frequency, often to beyond its original position. If during the second 
stage the pneumogastrics be cut, the pulse instantly becomes very rapid. 
It would seem probable that the first lowering of the pulse is due to 
an action on the inhibitory nerve, as is believed to be the case by Rosen- 
thal; but it appears to me that other investigations are required before 
this can be considei-ed as established. Traube, indeed, states that if the 
pneumogastrics are cut during the second stage the pulse becomes at 
once very rapid; but he also affirms that previous division of the par 
vagum does not prevent the slowing of the pulse. In the experiments 
of Tugenhold (reported by Rosenthal) upon frogs, the primary slowing 
of the heart amounted at first to a diastolic arrest, which was not pre¬ 
vented by previous division of the par vagum, but did not occur when 
very large doses of woorara were given. Rosenthal argues from this 
that nicotine stimulates the extreme peripheral inhibitory apparatus of 
the heart,—the reason that the curare prevents the primary retardation 
of the pulse being the paralysis of the inhibitory peripheral filaments 
which it is believed to cause. It is clear, however, that the results ob¬ 
tained by Rosenthal are difficult to reconcile with the effects of section 
of the par vagum already quoted from Traube. The method in which 
nicotine primarily lessens the pulse-rate must therefore be considered 
as still unsettled. The later increase of the pulse-rate appears to be 
due to paralysis of the peripheral inhibitory apparatus, since Rosen¬ 
thal found that in this stage of the poisoning the strongest galvanic 
currents applied to the pneumogastrics failed to influence the cardiac 
pulsations. The causes of the rise and fall of the arterial pressure 
have not been determined, but they are pi*obably connected with the 
at present undetermined vaso-motor action of the drug. Traube found 
that they both occurred after section of the vagi, and that in these 
circumstances minute successive doses would produce after each a 
temporary rise of pressure until a large amount of the poison was 
given, when the pressure steadily fell. Rosenthal believes that the 
dilated vessels which various observers have noted in the ear of the 
poisoned rabbit prove that the alkaloid finally paralyzes the vaso-motor 
system. 

Pupil .—When exhibited in a moderate toxic dose, or when applied 
directly to the eye, nicotine produces a very marked contraction of the 
pupil. If, as is asserted by Ivrocker, the alkaloid contracts the pupils 
of cut-out eyes, it is evident that the action is a local one. Hirsehmann 
(. Reichert's Archiv, 1863) has found that galvanization of the divided 
cervical sympathetic fails to cause dilatation of the pupil. Krocker, 
in later experiments, has confirmed this in regard to large doses of the 
drug, but has found that myosis occurs long before the sympathetic 


DEPRESSO-MO TORS. 


319 


is unable to dilate the pupil. This fact renders it probable that the 
alkaloid paralyzes the peripheral endings of the sympathetic; but it is 
barely possible that it induces a spasm of the fibres supplied by the 
oculo-motor so powerful that the sympathetic is unable to overcome it. 
Be this as it may, it is very probable that the sympathetic paralysis, 
if it exists, is associated with oculo-motor spasm; but at present we 
have not sufficient evidence to warrant any definite conclusion. 

Abdominal Organs. —Nasse found in his experiments ( Beitrdge zur 
Pliys. der Darmbewegung , Leipsic, 1866) that injections of nicotine into 
the jugular vein produced a tetanic contraction of all the intestines, 
which was not affected by section of the vagi or by compression of the 
abdominal aorta; even the splanchnics were unable to exercise their 
inhibitory influence, either because they were paralyzed or because the 
spasm was too intense for them. 

In what way the poison is eliminated has not, that I am aware of, 
been determined, but it very probably escaj)es with the urine, since, 
according to Claude Bernard ( Substances Toxiques, p. 410) the rapidity 
of the secretion of that fluid is increased. 

Therapeutics. —Tobacco has been employed in past times in a large 
number of diseases, but has almost passed out of sight as a therapeutic 
agent, and there are only two indications which it is capable of meeting. 
These are as follows: 

To relax spasm. —Imperfect as is our knowledge of the physiological 
action of tobacco, so far as it goes it indicates very clearly the great 
power of the drug in quieting violent muscular spasms. The frightful 
nausea and vomiting which it is so apt to induce, and the occasional 
excessive violence of its action, have led to its being superseded by less 
disagreeable and more controllable remedies. It is still, however, em¬ 
ployed occasionally in tetanus , with asserted good results. In spasmodic 
asthma, if the patient be not accustomed to smoking, one or more strong 
cigars will very often at once end the attack, or perhaps abort one 
which is threatening. In strychnine-poisoning , tobacco has been used in 
several cases successfully. 

To alleviate pain. —Taken internally, tobacco has no powers of re¬ 
lieving pain at all commensurate with the danger attending its use, and 
it should never be emplo 3 r ed for that purpose. It is different with its 
local use: thus, it is often added with great advantage to ointments in 
the case of painful hemorrhoids; and in pruritus a strong wash of 
tobacco affords one of the surest modes of relief. It must never be 
forgotten that its external employment has led to the most serious 
and even fatal poisoning.* For this reason tobacco ought never to be 
employed, as it formerly Avas, to kill vermin on the person. 

Toxicology. —A large number of deaths ha\ r e resulted from the 
medicinal use of tobacco, Husemann stating ( Handbuch der Toxicologie, 


* For a number of cases, see Stille’s Therapeutics, vol. ii. p. 374. 




320 


GENERAL REMEDIES. 


vol. ii. p. 483) that no less than ten fatal cases have been caused by 
tobacco enemata alone. Dr. Copland has seen a clyster containing half 
a drachm produce death (Diet, of Pract. Med ., art. Colic). Even smoking 
has caused an acute fatal poisoning. Melsens affirms that the smoke 
of half an ounce of strong tobacco contains sufficient nicotine to prove 
fatal.* In the only case of criminal nicotine-poisoning on record, an 
unknown amount of the alkaloid was forced into the mouth of the 
victim, causing death in from three to five minutes (Ann. d'Hygiene, 
1861, ii.). The treatment of tobacco-poisoning consists in washing out 
the stomach, the free administration of ammonia and alcohol, the 
hypodermic use of moderate amounts of strychnine, and the employ¬ 
ment of such external measures as dry heat, rubbings, etc. If these 
fail, artificial respiration should be maintained. The excessive use of 
tobacco produces in some persons serious nervous disturbance, such as 
insomnia, irritability, general feebleness; the most characteristic symp¬ 
tom is a peculiar irregularity of the heart’s action, often accompanied 
by distinct intermissions. Amaurosis is also sometimes present. Jona¬ 
than Hutchinson affirms (Med. Times and Gaz., 1884, i. 40) that he has 
seen this amaurosis recovered from by the use of opium and champagne 
without the abandonment of the habit of smoking. 

Administration. —The dose of tobacco in substance is usually stated 
to be five grains, which may be given in infusion. In strychnine¬ 
poisoning and tetanus the remedy should be exhibited at short intervals 
until constitutional symptoms are induced. 

CONIUM. U.S. 

The U.S. Pharmacopoeia recognizes both the leaves and the fruit of 
Conium maculatum. The fruit should be full-grown, gathered while 
yet green, and carefully dried. The plant is umbelliferous, a native of 
Europe, but naturalized in the United States. The dried leaves have a 
strong heavy odor, increased by the addition of an alkali, and resem¬ 
bling somewhat that of mice. They are bi- or triqfinnate, and very much 
incised. The fruits are one to two lines long, roundish-ovate, striated, 
with five crenated ribs on the outer sides of the easily-separable halves; 
the odor is that of the leaves. The active principle is Conine, a yellow¬ 
ish, oily, liquid alkaloid, highly volatile, of a strong odor similar to that 
of the urine of mice, and of a very acrid taste. It is freely soluble 
in alcohol and in ether, and slightly so in water, with which it forms a 
hydrate, and it coagulates albumen; when exposed to the air it under¬ 
goes decomposition, becoming first brown, afterwards resinous; heat 
accelerates the change. 

Physiological Action.—T he chief symptom produced in man by 


* The activity of tobacco-smoke is connected with the presence in it of other substances 
than nicotine (see Comptes-Rendus, xc. 1538). A. P. Fokker found a large proportion of 
carbonic oxide, and asserts that animals immersed in the smoke die of poisoning by that gas. 



DEPRESSO-MO TORS. 


321 


conine when taken in doses just large enough to impress decidedly the 
system is great muscular weakness or languor, with some disorder of 
vision, and giddiness. On attempting to walk, the patient suffers from 
a feeling as though his feet were made of lead, and staggers or falls 
from the refusal of his knees to support him. There is an intense 
desire to lie quiet in the horizontal position, and, as the eyelids are 
especially affected, the eyes are kept shut. In some subjects these 
symptoms are preceded or accompanied by burning in the mouth or 
fauces, nausea, and even vomiting, besides heat of head, often with a 
sense of weight or pressure, or even severe frontal pain. The dis¬ 
order of vision is apparently due in great part to a sluggishness and 
finally to a paralysis of accommodation. The experiments of Poehl- 
rnann (quoted by Husemann, Die Pflanzenstoffe, p. 269) show that very 
grave symptoms may be induced and yet the pupil remain natural; but 
sooner or later, as the drug gains power over the system, it probably 
always dilates. The pulse is first diminished, afterwards increased, in 
frequency. In decided poisoning by conium the symptoms are prob¬ 
ably simply those already mentioned, intensified. I have met with 
accounts of but four fatal cases of such character. In one, that of the 
mistress of Dr. Hermann Jahn, killed in a few minutes by from ten to 
fifteen drops of the alkaloid (quoted by Husemann, Die Pflanzenstoffe, 
p. 269), violent palpitation of the heart is said to have been a prominent 
symptom. The chief symptom in the second case ( Edinb. Med. and 
Surg. Journ., 1845) was universal paralysis, with total failure of volun¬ 
tary movement and of the voice before consciousness was lost. Con¬ 
vulsive movements were present very late in the case. Sensation 
appeared not to be lost until death was at hand. 

The third case was in the person of a medical electrician, suffering 
from blepharo-facial spasm, who took, beginning four hours after the 
last of a previous series of divided doses of a fluid exti*act amounting 
to one hundred and eighty drops, at 4.10, 4.40, and 5.15 p.m. fifty minims 
(one hundred and fifty in all) of “ Squibb’s fluid extract.” The first 
dose produced dizziness and muscular relaxation; the second, great 
muscular weakness, inability to stand, and thickening of speech, without 
relief of the spasm; the third, immediately, some nausea, and tremors 
about the chest. At 6.10 there were nausea, intense muscular weak¬ 
ness, partial ptosis, diplopia, and great difficulty of speech; the pulse 
was 60. Shortly after this he became unable to speak or to swallow. 
He made signs for electricity, and, on being asked whether the chemical 
or the faradic current, indicated the latter, and also the place of appli¬ 
cation of the electrodes, but was unable to hold one of the latter. 
Shortly after this, on being raised up, he dropped dead. ( The Sani¬ 
tarian, June, 1875.) A fourth case, in which a child five years old died 
of asphyxia preceded by coma and paralysis as the result of taking a 
drachm of chloroform-water containing five grains of the extract of 
conium, is recorded in Pharm. Journ. Trans., xvi. 102. 

21 


322 


GENERAL REMEDIES. 


In mammals conium produces symptoms parallel with those observed 
in man, and it probably acts similarly upon all vertebrates. In frogs 
convulsions are rarely if ever present; in birds they are occasionally 
so; in mammals they are more frequent,—thus, Ihmsen saw them in 
twelve out of twenty-three experiments; they are chiefly clonic, but 
tonic spasms do occur in the hind legs. As the legs are usually af¬ 
fected before the arms in man, so in quadrupeds the hind extremities 
are usually paralyzed first. Sensibility is maintained to the last. The 
respiration is generally much affected, and the heart continues to beat 
after its cessation. 

The occasional salivation and excessive sweating of conine-poisoning 
indicate that the alkaloid escapes with all the secretions; but the kid¬ 
neys are undoubtedly the chief channel of elimination. Zaleski and 
Dragendorff have found it abundant in the urine during the first 
twelve hours of the poisoning; Prevost has seen the urine of poisoned 
animals cause in a frog the characteristic general palsy, and in a doubt¬ 
ful case this physiological test might decide the diagnosis. 

Nervous and Muscular Systems .—All observers agree that the chief 
symptom produced by conine (i.e., the paralysis) is not due to any direct 
influence upon the muscles, which, indeed, preserve perfectly their con¬ 
tractility up to death. In 1856, Kolliker ( Virchow s Archiv, Bd. x. p. 
228) announced that the failure of motion in conine-poisoning is caused 
by a direct action of the alkaloid upon the efferent or motor nerves. He 
first experimentally found that in frogs killed by the drug the applica¬ 
tion of the galvanic current to a nerve fails to induce contractions in 
the tributary muscles. He then tied the aorta in such a way as to cut 
off the supply of blood to the hind extremities, and found that after 
voluntary motion had ceased in the fore legs, and even after galvanic 
stimulation of the anterior nerves had lost its influence upon the mus¬ 
cles directly supplied by those nerves, irritation of the same anterior 
nerves produced reflex contractions in the hind legs, showing that the 
anterior afferent nerves and the spinal cord still retained functional 
activity after the loss of it in all those efferent neiwes reached by the 
poison. After repeating these experiments a number of times, he drew 
the conclusion already given. 

His experimental results have been confirmed by Funke ( Berichte 
uber die Verhandl. der k. sacks. Gesellsch. d. Wissensch. zu Leipzig , Bd. xi. 
p. 23, 1859), by Guttmann ( Berlin. Klin. Wochenschr., 1868, quoted by 
Husemann), and by MM. Pelvette and Martin-Damourette* ( Gazette 
Med., 1870, quoted in Archives Gen., 6e ser., t. xvi. p. 88). The latter 
observers extended the series by severing in a frog all the tissues at 
the upper part of the thigh except the nerve, and found that when a 
batrachian so prepared was poisoned with conine, after the paralysis 

* M. Tiryakan (Compt.-Rend., lxxxvi. 1344) has affirmed that absolutely pure conine does 
not affect the nerves, but M. Prevost {Arch. Physiol. Norm, et Path., 1880, vol. vii.) has shown 
that chemically pure bromohydrate of conine has this action. 



DEPRESSO-MO TORS. 


323 


was complete in all portions of the body to which the poison had 
access,—after stimulations of the poisoned nerves were powerless to 
excite contraction in the tributary muscles,—the leg which had been 
protected from the action of the conine upon it responded not only to 
irritations applied to its nerve, but also to stimuli placed upon distant 
portions of the body. These same observers also noted that when 
conine and strychnine were given simultaneously to a frog from one 
of whose sciatic nerves the circulation ( i.e., direct access of the poison) 
was cut off in either of the manners spoken of, they produced by their 
conjoint action a commingling of paralysis in all other parts of the 
body with violent tetanic spasms in the protected leg,—a commingling 
explainable only on the supposition that the conine paralyzed all the 
motor nerves to which it had access through the circulation. Since B. 
F. Lautenbach ( Phila. Med. Times, vol. v.), Verigo, A. W. Hofmann, 
Professor Prevost, 11. Schultz (Schmidt’s Jahrb., cxlix. 16, cxcv. 119), 
and Fliess ( Arch.f. Physiol., 1882, p. Ill) have confirmed these experi¬ 
ments, it must be considered as an established fact that the chief 
physiological action of conine is as a paralyzer of the motor nerves, and 
primarily of their peripheral filaments* * 

It has generally been believed that conium does not affect the sensory 
nerves; but in 1875 (Bull. Therap.) M. Gubler called attention to its 
local influence in benumbing the cutaneous sensibility, and Lautenbach 
(Proc. Acad. Nat. Sci., Phila., 1875) found that when he tied the abdom¬ 
inal aorta and left axillary artery in the frog, and then injected a new 
dose of conine into the abdomen, irritation of the leg whose nerve was 
not protected from the poison failed to cause reflex movements at a 
time when irritation of the protected nerves produced reflex actions in 
distant parts of the body. These experiments seem to show that the 
alkaloid is a paralyzant to the sensory nerves; but it certainly acts upon 
them much less powerfully than it does upon the motor nerves. 

The exact influence of conine upon the spinal cord cannot yet be 
considered absolutely determined, but it is most probable that the poison 
has a feeble depressant action. Dr. Verigo (Schmidt’s Jahrb., cxlix. 16) 
asserts that it is a powerful spinal depressant, and MM. Pelvette and 
Martin-Damourette (Arch. Gen., 6e ser., t. vi. p. 89) say that it acts as 
an excitant. Dr. Lautenbach (Proc. Acad. Nat. Sci., Phila., 1875), in 
carefully investigating the subject, failed to obtain, under any circum¬ 
stances, evidences of excitement of the cord; he did succeed in pro¬ 
ducing loss of reflex activity where the nerve was protected by tying 
the artery in the limb, but, as in all but two of fifty-two experiments 
the reflexes in the protected limb were not greatly reduced until just 
before death, it is plain that any action upon the spinal cord is unim- 


✓ 

* H. Tlryakan ( Etude expirim. et chir. sur la Coniine, Paris These, 1878) endeavors to 
show that this action of conine is due to an impurity, and not to the alkaloid; but this is 
a priori exceedingly improbable, and Professor Prevost (Arch, de Physiol., Nov. 1880, 40), 
using the same preparation as did Tiryakan, has found that the motor nerves are affected. 



324 


GENERAL REMEDIES. 


portant and dominated by the more powerful influences of the poison. 
The experimental results obtained by Drs. A. D. Davidson and D. Dyce 
Brown ( Med. Times and Gazette , July, 1870), which have been cited as 
favoring the absurd theory of Dr. Harley that the corpora striata are 
especially affected by the drug, depended no doubt upon an arterial 
anomaly said to be common in the leg of the cat. 

According to the experiments of Lautenbach ( loc. cit., p. 451), the 
convulsions of hemlock-poisoning are cerebral, since, in a number of 
cases, after division of the cord they were confined to those muscles 
supplied by nerves arising from that portion of the spinal marrow above 
the section. 

The retention of consciousness and of the mental faculties so late in 
the course of poisoning by conine proves that the drug has but little 
influence upon the cerebral hemispheres. 

Pupil. —The pupil is generally dilated by conine; but both Yon 
Praag (Journ. fur Pharmacodyn., Heft i. p. 31) and Verigo assert that 
the phenomenon is not constant, at least in animals. The ptosis of 
conium-poisoning indicates that the dilatation of the pupil is due to 
oculo-motor paralysis. The known action of the drug upon nerve-trunks 
indicates that this paralysis is peripheral,—a conclusion corroborated 
by the experiments of Dr. I. Hoppe (Die Nervenwirk. der Heilmittel , 
Heft i., Leipsic, 1855) and of Lautenbach, each of whom found that 
when conine is dropped into the eye of an animal it causes at first con¬ 
traction, apparently due to the intense irritation, and afterwards dila¬ 
tation, of the pupil. 

Temperature. —Yerigo, Yon Praag, and others affirm that lethal 
doses of conium cause a decided lowering of temperature; but Lauten¬ 
bach asserts that the drug decidedly increases the temperature both 
when in therapeutic and when in toxic doses. 

. Circulation. —Ho sufficient investigation has as yet been made upon 
the action of conine upon the circulation. Lautenbach states that the 
arterial pressure falls immediately after the injection of conine, and 
afterwards rises far above the normal point, and that the pulse is at first 
accelerated, but afterwards retarded. The secondary rise of pressure 
was probably due to asphyxia. The primary pulse-acceleration is ex¬ 
plained by the observation of M. Pelenard, confirmed by M. Prevost, 
that the pneumogastrics are paralyzed before the motor nerves. M. 
Prevost finds that the heart itself is scarcely affected at all by the 
poison. 

When locally applied in a concentrated condition, conine probably 
is fatal to all the more highly organized tissues. Certainly Christison 
(Edinburgh Philosoph. Trans., vol. xiii.) proved this to be so in regard to 
the muscles, although these organs are not influenced by conine taken 
internally. Upon the mucous membranes it acts as an intense irritant. 

Summary. —The chief symptom of poisoning by conium is a failure 
of voluntary and involuntary movement, the result of a progressive 


DEPRESSO-MO TORS. 


325 


paralysis of the motor nerves. The cerebrum is not atfected, hence 
consciousness is preserved to the last. The pupil is dilated by a periph¬ 
eral paralysis of the oculo-motor nerve. The sensory nerves and the 
spinal cord are probably feebly depressed. It is probable that the 
alkaloid does not directly act upon the circulatory apparatus except to 
paralyze the pneumogastrics. 

Therapeutics.— The paralytic action of conium naturally suggests 
its use in spasmodic affections; and accordingly it has been tried in 
chorea , in paralysis agitans, in whooping-cough, and in other diseases of 
similar nature. Although it seems not to have met with continued 
favor, and is but little used, it may be employed when life is threatened 
by the mere convulsive actions, as it will suspend these for the time 
being. If Dr. Harley’s views as to its physiological action be correct, 
it ought to be especially useful in all motor disturbance connected with 
irritation at the base of the brain. Clinical proof is, however, nearly 
as scarce as physiological in this matter. 

In maniacal and hysterical excitement, the drug in full doses is said 
to produce a condition of calm and relaxation which is highly favor¬ 
able ; and in the treatment of the insane, conium is very much used by 
some alienists (Amer. Journ. of Insanity , April, 1873). 

Conium has also been employed to relieve pain. As a deobstruent 
and alterative it has been very largely used, both locally and internally, 
in neuralgia and sciatica, with asserted occasional success, in cancerous 
and other tumors , in chronic glandular enlargements , in swollen joints, and 
in various chronic ulcerations. Dr. H. Kennedy ( Dublin Journ. Med. 
ScL, Jan. 1874) especially commends it in chronic rheumatism , and as an 
aid to cod-liver oil, etc., in chronic phthisis. It has also been employed 
to arrest the secretion of milk and to relieve dysuria. The various uses 
of conium as an alterative certainly have no definite physiological basis, 
but they appear to be justified to some extent by clinical experience. 

Administration.— One of the great practical drawbacks to the use 
of this drug is the uncertainty of its preparations. The dose of the 
abstract ( Abstractum Conii, U.S.) is one to two grains; of the extract 
( Extractum Conii Alcoholicum, U.S.), one grain; of the tincture ( Tinctura 
Conii —1 to 6.6, U.S.), f3ss to f5i; of the fluid extract ( Extractum Conii 
Fluidum ), nj?j to njj ii: all of which must be administered in increasing 
doses until some effect is experienced. Of these preparations the last 
is certainly the best. The English Succus Conii, so praised by some 
writers, I have known to be used by the ounce without effect. 

The variability of all the preparations has its origin—first, in the 
varying amount of the active principle in the drug; secondly, in the 
great volatility of this principle; and thirdly, in the proneness of the 
alkaloid to undergo spontaneous decomposition, even when kept under 
the most favorable circumstances, and to a much greater extent when 
exposed to light and air. The alkaloid, on the whole, would probably 
be the best form in which to use the remedy; but it is not officinal: 


326 


GENERAL REMEDIES. 


it has been used abroad to a considerable extent. Its unstable 
nature, however, is an obstacle to its use, and has caused M. Mourrut 
to propose its hydrobromate, which is said to be a crystalline stable 
salt {Bull. Therap., xc. 446, xci. 1). The dose of the alkaloid or of its 
salt is one-twentieth to one-twelfth of a grain, which may be dissolved 
in alcohol. 

Toxicology.— Sufficient has been said about the symptoms caused 
by conine. After death from it no distinctive lesions are to be found, 
only the usual indications of death from asphyxia. The treatment 
consists in the immediate evacuation of the stomach and the exhi¬ 
bition of tannic acid,—the tannate formed is, however, probably more 
or less poisonous,—with the use of external heat and of internal stimu¬ 
lants; artificial respiration should be steadily maintained so long as 
there is the faintest indication of cardiac action. No physiological 
antidote is known; but it is possible that atropine might be of service 
by aiding to maintain the respiration. 


1 


ORDER II.—CARD I ANTS. 


FAMILY I.—CARDIAC STIMULANTS. 

The term cardiac stimulants is here used to designate a number of 
medicines which, when given internally, inci*ease the power and force 
of the circulation, and are used by the physician for such purposes. 
There are some substances which are heart-stimulants in reality, but 
which possess other properties in so great a degree as to overshadow 
their cardiac relations, and are not used by the physician to affect the 
circulation. Such medicines are considered in connection with those 
powers which give them their clinical value, and are consequently not 
included in the present class. Some of the members of this class 
are slow in their operation, some more rapid. Some produce increase 
in the pulse-rate, some lower it. It is evident, then, that no general 
indications can be laid down for their use, but that medicines so diverse 
must be studied individually. 


AMMONIA. 

Ammonia is a colorless, irrespirable, highly irritant gas, of a strong 
alkaline reaction, extremely soluble in water. It is obtained upon a 
large scale as a waste product in the manufacture of coal-gas, and is 
officinal in the Materia Medica list of the U.S. Pharmacopoeia in the 
forms of the stronger water of ammonia and the muriate, carbonate, 
nitrate, and sulphate of ammonium. 

Physiological Action. —Locally applied, ammonia is a very pow¬ 
erful irritant. When inhaled, it causes intense irritation and finally 
inflammation of the mucous membrane of the air-passages, and its 
solution, if kept in contact with the skin, reddens, blisters, and at last 
produces even sloughing of the parts. When ammonia is injected into 
the veins of animals in considerable quantities, it causes violent con¬ 
vulsions, with remarkable disturbance of the respiration, followed, if 
the dose has been large enough, by death in a very short time. (F. 
Lange, Archiv fur Experiment. Path, und Pharm., Bd. ii. p. 368; Y. Feltz 
et E. Fitter, Journal de VAnatomie et de la Physiol., 1874, p. 326; Funke, 
PHuger's Archiv , Bd. ix. p. 426.) The respiration, if not interfered with 
by the tetanus, is enormously accelerated. Billroth ( Archiv fur Klin. 
Chirurg ., Bd. vi. p. 421) states that the temperature falls enormously 
in animals poisoned with ammonia. 


327 



328 


GENERAL REMEDIES. 


Respiration .—When a small quantity of ammonia is injected into 
the blood of an animal, the breathing is greatly accelerated; after 
larger doses a period of arrest of respiration occurs in expiration 
(Funke), at once or in the course of a few seconds, and precedes the 
hurried breathing. In regard to the effect of section of the pneumo- 
gastries upon the respiratory action of ammonia there is some dis¬ 
agreement : thus, in Funke’s observations the primary arrest of respi¬ 
ration was always present, while in the experiments of Lange it was 
always absent. Both observers note, however, that section of the 
pneumogastrics does not interfere with the increased rapidity of the 
breathing, and Funke especially remarks that the change from the 
slow, deep breathing of divided vagi to the extremely rapid respira¬ 
tion of ammonia-poisoning is colossal. Our knowledge of the physi¬ 
ology of respiration is hardly sufficient to warrant a positive deduc¬ 
tion ; but the facts noted indicate very strongly that ammonia is an 
intense direct stimulant to the respiratory centres in the medulla 
oblongata. 

Circulation .—The main practical interest in the physiological action 
of ammonia centres in the circulation. It is chiefly as an arterial 
stimulant that it is used in medicine, and clinical experience assigns to 
it a powerful but fugacious action on the heart. The only experiments 
on the subject besides my own that I have met with are those of Lange. 
When the drug is injected into the veins of animals there is a momen¬ 
tary fall of the arterial pressure, followed by a sudden, decided rise, 
and a corresponding increase of the pulse-rate. These phenomena are 
independent of the convulsions, because in Lange’s experiments they 
occurred in curarized animals. According to Lange’s studies, the rise 
of pressure is not due to any stimulation of the vaso-motor centre, 
because it took place equally after division of the cord,— i.e., after the 
separation of the arterioles from the vaso-motor centre. The increased 
arterial tension which follows the exhibition of ammonia must there¬ 
fore be due to an action either upon the heart itself, or upon the 
peripheral vaso-motor nerve-fibres, or upon the muscular fibres in the 
coats of the arteries. As in Lange’s experiments the increase of the 
pulse-rate did not accompany the rise of pressure after section of the 
’spinal cord, it would seem to be caused by a stimulant action upon 
the accelerators of the heart, which are of course paralyzed by spinal 
section. The fall of arterial pressure which immediately follows the 
injection of ammonia into the jugular vein is probably due to a direct 
action of the concentrated poison on the heart. Previous section of 
the vagi does not prevent it, and when the dose is sufficient it is re¬ 
placed by permanent diastolic arrest of the heart’s action. That it is 
not produced by spasm of the pulmonic arteries is shown by the fact 
that when death occurs the left heart is found full of blood. When 
administered in toxic doses, ammonia probably has some effect upon 
the hsemic corpuscles, for Feltz and Bitter found that the blood of a dog 


CARDIAC STIMULANTS. 


329 


killed by the poison not only did not contain anything like the normal 
amount of oxygen, but even when shaken up with the gas refused to 
absorb it; further, under the microscope the red disks were found to 
resist the action of acetic acid to a markedly abnormal degree. 

Motor System. —The convulsions already spoken of as being pro¬ 
duced by ammonia are not cerebral, since Lange found that they occur 
equally after division of the cord; nor are they peripheral, since in 
Funke’s experiments tying of the artery of a limb failed to arrest 
them in that part, while section of the nerve was followed by imme¬ 
diate quiet: they must be spinal. Ammonia, in toxic doses, acts, there¬ 
fore, as a stimulant to the motor function of the spinal cord, heightening, 
as has been proved experimentally by Funke, its reflex activity. 

Elimination. —The volatility of ammonia and the extreme fugacious¬ 
ness of its action would seem to indicate its elimination by the lungs; 
but Feltz and Ritter ( loc. cit., p. 323) Aided to find it in the breath of 
a poisoned animal, and the researches of H. Bence Jones apparently 
demonstrate that at least a portion of it is oxidized in the system 
(.Philosophical Transactions , London, 1851). The last observer found, 
to his surprise, that even large doses, far from increasing the alkalinity 
of the urine, seem at times to heighten its acidity. It occurred to him 
that the ammonia might be oxidized; and he accordingly found that 
the natural product of its oxidation, nitric acid, appears in the urine 
after the exhibition either of ammonia itself or of its tartrate, car¬ 
bonate, or muriate. It is probable that some portion of the ammonia 
is, in conjunction with carbonic acid, converted into urea.* 

Therapeutics. —Externally, ammonia is much used as a constituent 
of irritating liniments, and, on account of its efficiency and cheapness, 
is very valuable. By inverting a watch-glass full of the stronger water 
of ammonia upon the skin, a blister may be raised in a very few min¬ 
utes ; but, as the effects of the application are apt to be severe, the use 
of it is justifiable only under rare circumstances. 

Internally the chief indication for the use of ammonia is failure of 
the heart's action. The more sudden and purely functional this is, the 
more efficacious is the remedy, which should in such cases be not only 
administered by the stomach, but also inhaled through the nostrils, as 
the local action of the irritant vapor upon the mucous membrane has a 
very arousing influence. When the failure of the circulation depends 
upon a slow and persistent cause, as in adynamic fevers , ammonia is 
not generally useful, but may be employed as an adjuvant to alcohol 
in the crisis of the disorder. 

In poisoning by venomous serpents , ammonia has been largely used, 


* The relation of ammonia to the formation of urea is of such purely physiological 
interest, and its discussion would require so much space, that I dismiss it with the following 
references, which will give the reader a sufficient key to the literature: Arch. /. Exper. Path, 
u. Pharm., ii., viii., x. 125, xii. 77; Zeitschr. f. Phyaiolog. Chem., ii. 29, iv. 36; Zeitachr. f. 
Biol., xiv. 



330 


GENERAL REMEDIES. 


but certainly is in no sense antidotal, since, according to the experiments 
of Dr. Fayrer ( Indian Annals of Medical Science , 1872), mixing it with 
the poison before injecting the latter into an animal does not in any 
way delay the fatal result. As an adjuvant to other more powerful 
stimulants, and especially to alcohol, ammonia may be useful in these 
cases. Dr. G. B. Halford, of Melbourne, Australia, has asserted ( Mel¬ 
bourne Argus, 1872) that when injected into the veins its effects in 
poisoning from snake-bite are very extraordinary, and several cases of 
recovery after its use in this manner have been reported. It is far 
from certain, however, that these cases would have died had no medi¬ 
cation been practised; and Dr. Fayrer states that in an extended series 
of experiments upon animals he has not found injection of ammonia to 
be of any use. Ammonia is not a specific in snake-poisoning; but, as 
the injection can do no harm, it may be practised. 

In failure of the heart during anaesthesia ,* and in poisoning other 
than from snake-bite, hypodermic injections of ammoniaf have seemed 
in a number of reported cases to be of very great service. The same 
may be said of sudden collapse in disease, as sometimes is seen in the 
exanthemata , in cholera , and not rarely in pernicious malarial fever, J or 
after surgical operations or injuries. From fifteen to twenty-five minims 
of the aqua ammoniae fortior, diluted with four times its bulk of water, 
should be thrown directly into a vein of the arm, and repeated in fifteen 
minutes if necessary. 

Professor Stille and other authorities claim for ammonia an antidotal 
influence in alcoholic intoxication; but that it can relieve absolute 
drunkenness is, I think, very doubtful. Ammonia appears to have a 
tendency to act upon the mucous membrane of the lungs, and may be 
used as a stimulant expectorant in adynamic pectoral inflammations, as 
in typhoid pneumonia. As a stimulant antacid, it is frequently of ser¬ 
vice in cases of headache from gastric acidity. 

Toxicology. —When taken in large amounts, ammonia acts as a 
violent corrosive poison, producing generally abdominal pain, vomiting, 
bloody purging, and other symptoms of gastro-enteritis, with convul¬ 
sions, collapse, and finally death. In some cases symptoms of impend¬ 
ing suffocation, resulting in death from asphyxia, have occurred, and 
at the autopsy intense redness and congestion of the bronchial mucous 
membrane have been present, due no doubt to the irritant’s having 
found its way into the bronchi. The intellect may be clear to the very 
moment of death, or stupor, and finally coma, may be developed. In 


* Professor Ringer (Practitioner, xxvii.) finds that ammonia added to the frog’s heart de¬ 
pressed with chloroform, iodoform, etc., has a pronounced effect in re-establishing its action. 

f See Indian Med. Gaz., June 1, 1872, Med. Times and Gaz., Nov. 1872,- Chicago Med. 
Joum., 1872; London Med. Record, i., 1873; L’Abeille Med., Aug. 1874; Berlin. Klin. 
Wochenschrift, No. 24, 1874; Archives Gen., ii., 1874; Lancet, 1879, ii. 158 ; New York Med. 
Rec., xv. 532. 

J See Dr. Zuelzer, Revue de Thirap. Mid.-Chir., July 1, 1872. 



CARDIAC STIMULANTS. 


331 


the rare instances in which death has taken place within five minutes 
from the ingestion of the poison, the fatal result has probably been 
brought about by oedema of the larynx. When the sufferer survives 
the first few hours, recovery may occur; but death sometimes happens 
long afterwards from the organic lesions which have been produced. 
The treatment of poisoning by ammonia consists in its neutralization as 
soon as possible by vinegar or other dilute acid, and the meeting of 
indications as they arise. If the oedema of the glottis be threatening, 
tracheotomy should at once be performed. 

Administration.— There are four officinal preparations of uncom¬ 
bined ammonia itself,—namely, Aqua Ammonite Fortior ( Stronger 
Water of Ammonia ), sp. gr. 0.900, Aqua Ammonias ( Water of Ammonia ), 
sp. gr. 0.959, Spiritus Ammonite ( Spirit of Ammonia ), and Spiritus Am¬ 
monias Aromaticus, or Aromatic Spirit of Hartshorn, as it is usually 
called. 

To reduce the strength of the first of these preparations to that of 
the second requires the addition of one and a half measures of water. 
The spirit is of varying strength, but is somewhat weaker than the 
simple water. The aromatic spirit contains both ammonia and its car¬ 
bonate. For hypodermic use the waters of ammonia are to be preferred. 
The spirits, especially the aromatic, are best suited for internal use. 
The dose of the simple spirit is from twenty-five drops to a teaspoonful, 
properly diluted. 

The Carbonate of Ammonium , U.S. (Ammonii Carbonas, NH 4 0,C0 2 
—2NH 4 ), is the best preparation for continuous use and in typhoid 
pneumonia. It occurs in white, translucent, fibrous masses, which on 
exposure become opaque and efflorescent, parting with ammonia and 
passing from a sesqui- into a bi-carbonate. It is soluble in four and a 
half times its weight of water, and may be given in solution in doses 
of from five to ten grains, repeated pro re nata. 

The Nitrate of Ammonium (Ammonii Nitras, NII 4 0,N0 5 —jSTI 4 N0 3 ) 
is officinal for the preparation of nitrous oxide; the Sulphate (Ammonii 
Sulphas, NH 4 0,SO s —2NH 4 ,S0 4 ), for the preparation of Ammonio-ferric 
Alum. The Muriate of Ammonia will be considered under Expectorants. 

ALCOHOL. U.S. 

Absolute alcohol, i.e., alcohol free from water, is a colorless, volatile 
liquid, boiling at 172° F., not congealed by a cold of —166° F., and 
having the specific gravity of 0.796. It is not officinal, and is never 
used except for chemical purposes. 

The U.S. Pharmacopoeia recognizes Alcohol, containing 94 per 
cent, of absolute alcohol, and having the specific gravity of 0.820, and 
Alcohol Dilutum, Dilute Alcohol, containing 53 per cent, of alcohol, 
and having the specific gravity of 0.928. 

Alcohol also exists in the officinal Spiritus Frumenti, or Whisky, 
and Spiritus Vini Gallici, or Brandy, which are obtained respec- 


332 


GENERAL REMEDIES. 


tively by the distillation of fermented grain and of fermented grapes, 
and should contain from 48 to 56 per cent, of absolute alcohol, and in 
the officinal Yinum Rubrum, or Red Wine , and Yinum Album, or White 
Wine. For medicinal use, brandy should be at least four and whisky 
at least two years old. 

Alcohol is formed out of sugar by fermentation; but, as a dis¬ 
cussion of the natural history and chemistry of this process, to be of 
value, would occupy much space, the reader is referred for it to works 
especially devoted to chemistry and to materia medica. 

Physiological Action. —The phenomena induced by the ingestion 
of alcohol are, unfortunately, so well known as to make any description 
of them here unnecessary. I have not met with a close experimental 
study of the order in which the nervous centres are affected, but it is 
scarcely doubtful that alcohol acts upon them as does ether, except 
that the latter substance, being much more volatile than alcohol, is 
consequently absorbed and eliminated much more rapidly, so that its 
influence is more evanescent. I know by experiment that the vapor 
of alcohol is capable of producing the stupor known as anaesthesia, 
and, further, that this anaesthesia may be deepened into death, accompa¬ 
nied by all the phenomena of fatal ether-narcosis. The experiments of 
Mommsen ( Arch. f. Patholog. Anat ., lxxxiii. 243) would seem to show 
that alcohol acts slightly upon the peripheral motor nerves, as he found 
that when brought into contact with them it augmented their excita¬ 
bility. 

It is a well-known clinical fact that alcohol given to healthy men 
increases the frequency, and, to the fingers, the force, of the pulse. The 
very careful and elaborate experiments of Parkes and Wollowicz upon 
man with the sphygmograph indicate that there is produced by brandy 
an increased rapidity of the ventricular contraction, with shortening 
of the period of rest or diastole. The tracings furnished, however, no 
distinct indications of increased arterial pressure. Dr. H. Zimmerberg 
found that enormous doses of alcohol reduce both the rate and force of 
the pulse. After section of the vagi the alcohol lessened the arterial 
pressure without affecting the pulse-rate, whose slowing in the normal 
animal would therefore seem to be due to inhibitory stimulation. It is 
plain that Zimmerberg’s experiments apply not to therapeutic but to 
toxic doses of alcohol. J. Dogiel affirms that by moderate amounts of 
alcohol the arterial pressure is at first increased and then diminished. 
During the latter state the vaso-motor centres are found incapable of 
responding to stimulation. The rate of the heart-beat is stated to be 
at first increased, then diminished, then increased,—the first increase 
being owing to the stimulation of the accelerators, the diminution to 
stimulation of the par vagum, and the final increase to paralysis of the 
same. The action of alcohol upon the circulation has been carefully 
studied in the Pharmacological Laboratory of the University of Penn¬ 
sylvania by Dr. J. D. Castillo (Phila. Med. Times, xi. 45). He found 


CARDIAC STIMULANTS. 


333 


that in moderate doses the drug caused great increase in the rate and 
force of the cardiac beat and corresponding rise of the arterial pressure, 
and that these phenomena were not affected by previous division of the 
pneumogastries, of the accelerators, or of the spinal cord. These re¬ 
sults, so far as the pulse-rate is concerned, are in direct contradiction to 
those of Dogiel; but in regard to the arterial pressure they are partially 
in accord. On the other hand, closely corresponding with the results 
of Dogiel are the elaborate studies of Professor Martin (. Maryland Med. 
Journ., x. 292) upon the dog’s heart, isolated according to the manner 
invented by himself. Professor Martin found that blood containing 
one-eighth per cent, by volume of absolute alcohol has no immediate 
action upon the isolated heart; that blood containing one-fourth per 
cent, diminishes within a minute the work done by the heart; and that 
blood containing one-half per cent, always diminishes remarkably the 
heart-work and sometimes nearly destroys it, so that not enough blood 
is pumped out of the left ventricle to supply the coronary artery. The 
curious observation was made that cutting away the pericardium 
stopped the action of even one-half per cent, of alcohol. The explana¬ 
tion of this offered by Professor Martin is that the alcohol so relaxes 
the cardiac muscle that there is not room in the pericardium for a full 
diastole, the relaxed heart being, even in its systole, about sufficient^ 
large to fill the pericardium. This explanation is hardly satisfactory. 
Can there be a local inhibitory cardiac apparatus, with peripheral fila¬ 
ments in the pericardium which are irritated by alcohol, and whose 
removal prevents the action of the alcohol ? Whatever the explanation 
of Professor Martin’s results may be, it is clear that at present they do 
not warrant positive conclusions as to the action of alcohol upon the 
circulation. The experimental evidence is too fragmentary and contra¬ 
dictory to be put against the universal belief of clinicians, that small 
doses of alcohol increase the force of the circulation by directly acting upon 
the heart. Martin, Castillo, Dogiel, and Zimmerberg all agree that large 
doses of alcohol diminish very greatly arterial pressure. Castillo found 
that the lowering is produced after section of the cord, and that when 
it is very pronounced galvanic irritation of the sciatic causes a rise of 
pressure, showing that the vaso-motor centres are intact. This is in 
accord with the results of Martin, and it may be considered established 
that overdoses of alcohol directly depress and paralyze the heart-muscle; 
but it still seems probable that the fall of the pressure is also in part 
due to an influence exerted upon the arterial system. 

Owing no doubt to the sensations of warmth induced by its local 
action on the stomach and by the increased activity of the circulation 
in the extremities, alcohol has been looked upon as a promoter of animal 
heat. As long ago as 1848, however, Dumeril and Demarquay asserted 
that after the administration of large doses there is a fall of tempera¬ 
ture. Of late years much attention has been given to the subject, and 
positive results have been achieved. As almost all experimenters are 


334 


GENERAL REMEDIES. 


in accord, it does not seem worth while to occupy space with a discus¬ 
sion of the history of the subject. References are given to the principal 
original memoirs.* 

It is certainly demonstrated that lethal doses of alcohol produce in 
animals a fall of temperature which often amounts to 5° C., and that 
even when intoxication or alcoholic narcosis is alone induced the de¬ 
pression of temperature may amount to 3° C. The proportionate dose 
necessary to produce distinct nervous symptoms is enormous in the 
lower animals as compared with man; yet, after the ingestion of 
amounts of alcohol which are not enough to cause intoxication in the 
animal, the fall of temperature is slight,—rarely more than 1° C., and 
according to Ruge (Joe. cit., p. 265) usually from i° to i 0 C. 

The experiments of Richardson show that in some cases very minute 
doses of alcohol increase slightly the temperature (£° F. in mammals, 
1° F. in birds). As regards animal heat, alcohol acts upon man as upon 
the lower animals. After doses only sufficient to increase the activity 
of the circulation, probably as a result of this increase, there is some¬ 
times a very trifling exaltation of temperature (Parkes and Wollowicz). 
After larger doses there is a slight fall of temperature, and when full 
intoxication is induced this fall may amount to 3° F. (Ringer and 
Rickards.) 

Upon animals suffering from pysemic fever Bouvier and subsequent 
observers have found that alcohol exerts a decided antipyretic action, 
very large doses of it lowering the temperature as much as 81° C., and 
altogether preventing the occurrence of fever if narcosis be produced 
before the development of the latter. In fever in man alcohol exerts 
a similar influence, but in order to make its antipyretic action decidedly 
manifest, doses so large as to be toxic must be given (Ringer and 
Rickards). It has been noted both in man and in the lower animals 
(Bouvier) that when the individual is accustomed to the free habitual 
use of alcohol the temperature is scarcely affected even by large doses. 


* For those desirous of looking up the literature of the subject, the following references 
are given : 

N. S. Davis, Trans. Amer. Med. Assoc., 1855, p. 577. C. Bouvier, Pfluger’s Archiv, p. 
370, 1869; Obernier, Ibid., p. 499, 1869. A. Godfrin, De I'Alcool, son Action physiologique, 
ses Applications therapeutiques, Paris, 1869. C. Bouvier, Wirkung der Alcohol an/ die Kor- 
pertemperatur, Bonn, 1869. Manassein, Centralblatt fur die Med. Wissens., 1869. P. Rusre, 
Virchow’s Archiv, Bd. xlix. p. 265. C. Binz, Virchow’s Archiv, Bd. ii. p. 153; Practitioner, 
vol. iii., 1869, vol. v., 1870 ; Journ. Anat. and Physiol., vol. viii., 1874, p. 232; Sitzungsberichte 
der niederrheinischen Gesellschaft fur Natur- und Heilkunde, Mediz. Section, July 21, 1873. 
Brown-Sequard, Journ. de la Physiologie, 1859, p. 467. Jacobi, Deutsche Klinik, 1857. 
Tscheschichin, Reichert’s Archiv, 1866. Ringer and Rickards, Lancet, 1866, p. 208. Richard¬ 
son, Med. Times and Gaz., vol. ii. p. 704, 1869. Parkes and Wollowicz, Trans. Royal Soc., 
1870. Anstie, Stimulants and Narcotics, London. Mainzer, Inaugural Dissertation, Vir¬ 
chow’s Archiv, Sept. 1871. C. Bouvier, Centralbl. f. Med. Wissens., Dec. 1871. I. S. Lombard, 
Neic York Med. Journ., June, 1865. Sulzynski, Inaugural Dissertation, Dorpat, 1865. S. 
Rabou, Berlin. Klin. Wochenschr., 1871. Radziejewski, Centralbl. f. Med. Wissens., 1871. 
Gustav Strassburg (use in fever), Virchow’s Archiv, Bd. lx. p. 471. L. Lewin, Centralbl./. 
Med. Wissens., No. 38, 1874. 



CARDIAC STIMULANTS. 


335 


Dr. Franz Eiegel, of Germany ( Deutsches Archiv f. Klin. Med., 1873), 
made a very elaborate investigation upon the action of alcohol upon 
the temperature in man, performing as many as eighty-six experiments. 
The conclusions which he arrived at are in exact accord with those 
reached by most students of human phj^siology as well as by most ex¬ 
perimenters upon the lower animals. As his conclusions embody the 
whole subject in a single paragraph, and may be received as absolutely 
demonstrative, I give them in extenso. 

“ 1. Alcohol, even in moderate doses, in many cases causes a lowering 
of the temperature of the body. The amount of this diminution aver¬ 
ages, as a rule, only some tenths of one degree. 2. Only exceptionally 
is there noticed an elevation of the temperature consequent upon the 
administration of alcohol; not unfrequently, at least after minute doses, 
there is no noticeable change. 3. The diminution of temperature in 
convalescents is, as a rule, less than in healthy subjects, or it may be 
altogether wanting. 4. In those who habitually drink alcoholic stimu¬ 
lants, the depressing influence of alcohol upon the temperature is almost 
always wanting. 5. The frequent repetition of the doses of alcohol 
diminishes their lowering effect upon the temperature. 6. The amount 
of diminution of temperature is directly proportional to the dose of 
alcohol given. 7. The depression of temperature caused by alcohol is 
for the most part of but short duration, and the temperature soon re¬ 
turns to its previous grade.” 

The effect of alcohol upon the formation of animal heat was first 
properly studied by Dr. Bevan Lewis ( Journal of Mental Sci., xxvi. 20). 
He found that after the exhibition of alcohol in the rabbit there was 
sometimes a primary lessening of heat-production of very short dura¬ 
tion, which was followed by a marked increase in the heat-production. 
In some cases heat-dissipation more than kept pace with this increase 
and the bodily temperature fell; in other instances the bodily tempera¬ 
ture rose, showing that heat-production was excited more than heat-dis¬ 
sipation. Calorimetrical experiments made by myself and Dr. Reichert 
have arrived at similar results, but befoi*e it can be shown exactly how 
alcohol affects thermogenesis further experimentation is needed. It may 
be that the increased heat-generation is simply the result of the rapid 
burning up of the alcohol itself. The great fall of bodily temperature 
which occurs after toxic doses of the drug seems to me to be clearly 
due to excessive heat-dissipation, which in turn is the result of vaso¬ 
motor paralysis.* 

The effect of alcohol upon the elimination of carbonic acid by the 
lungs has been investigated by several observers, with different results. 
According to the researches of Bocker (Be it rage zur Heilkunde insbeson- 
dere zur Krankheitsgenussmittel und Arzneiwirkungs Lehre , abstracted by 
Claude Bernard in Journal de Pharmacie , tom. xv., 3d series, 1849), of 

* Professor Binz’s experiments and inferences upon this subject, in the light of recent 
evidence, seem of no value. 




336 


GENERAL REMEDIES. 


N. S. Davis ( Transactions of the American Medical Association, 1855), 
of Hammond ( Physiological Memoirs, Philadelphia, 1863), of M. Perrin 
(.Archives Generates, 6th series, tome iv.), of Boeck and Bauer ( Zeitschr. 
f. Biologie, 1874, x.), and of Bumpf ( Pfiuger's Archiv, 1884, xxxiii.), 
there is a lessening in the amount of carbonic acid gas exhaled; on 
the other hand, Dr. E. Smith (Brit. Med. Journ., 1859) found that 
small doses of alcohol increased the elimination of the gas, although 
brandy, whisky, and gin always lessened the production. Henrique 
(Bull. Acad. Boy. de Beige, v. 1883) found in himself that the consump¬ 
tion of oxygen was increased by alcohol. Wolfers (Pfiuger's Archiv, 
1883, xxxii.) noted in the rabbit an increase both of the oxygen inges¬ 
tion and of the carbonic acid elimination. The most recent and appar¬ 
ently most careful and reliable of these researches upon the effect of 
alcohol upon the consumption of oxygen in the system are those of 
Bodlander (Zeitschrift f. Klin. Med., 1886, xi.) upon rabbits and dogs, 
and of Zuntz (Fortschritte der Med., 1887, i.) and G-eppert (Archiv f. 
Fxper. Path, und Pharm., xxii.) upon man. Bodlander noted reduction 
of the oxygen consumption, Zuntz increase, and Geppert “ no important 
effect.”* 

One of the most important facts to be determined about alcohol is 
its influence upon the excretion of nitrogenous material. Bbcker is 
commonly believed to have experimentally determined that it lessens 
the excretion of urea. I have seen only an abstract of the original 
paper. In it this is not positively asserted, but seems to be inferred. 
Dr. Hammond has performed a very elaborate series of experiments 
upon himself: first, when just sufficient food was taken to maintain the 
weight of the body; secondly, when more than enough for that purpose 
was ingested; thirdly, when not enough was taken. Under all these 
circumstances, urea, chlorine, and phosphoric acid were lessened in 
amount by the ingestion of alcohol. Parkes and Wollowicz (loc. cit .) 
affirm that their experiments gave a contrary result. In examining 
the reports of their experiments I find, however, that on one of the 
days the man taking the alcohol had a chill followed by fever. If this 
day be omitted, the average daily excretion of urea during the alco¬ 
holic period was 34.35 grammes ; during the time when brandy was 
taken, 34.8 grammes; and during the water period, 35.02 grammes. 
The ingestion of alcohol seems, therefore, to have reduced the elimina- 


* For a more detailed discussion of the matter than is compatible with the amount of space 
available in this book, the reader is referred to the paper of Dr. J. W. Warren (Boston Med. 
and Surg. Journ., July, 1887). The contradictory nature of the evidence, to my mind, is prob¬ 
ably in part due to the experimental difficulties of the subject, but at the same time strongly 
indicates that moderate doses of alcoholic spirits have no constant very decided action upon 
the formation and elimination of carbonic acid. It is readily conceivable that by checking or 
aiding digestion, by influencing circulation, or in some other way, they may exert a varying 
indirect action, which is superior to the slight direct influence in lessening carbonic acid pro¬ 
duction, which the weight of evidence indicates that they possess. 



CARDIAC STIMULANTS. 


337 


tion of urea by about ten grains a day. Recently very careful experi¬ 
ments have been made by L. L. Rieso {Hoffmann und Schwalbe's Jahresb ., 
1881, 357) upon two persons under rigid conditions. The exhibition of 
alcohol was followed by great lessening of the excretion of urea, and 
to a less pronounced degree of uric acid, chlorides, phosphates, and 
sulphates, and at the same time an increase of the bodily weight. 
These results are in strict accord with those of Hammond, and it must 
be considered fairly proved that alcohol causes a great lessening in the 
excretion of the products of tissue-waste. 

From the time of Liebig’s celebrated classification of food until the 
appearance of the memoir of MM. Lallemand, Duroy, and Perrin, in¬ 
gested alcohol was almost universally believed to be burnt up in the 
body. These latter observers asserted, however, that alcohol escapes 
unchanged from the body, not only because they were unable to detect 
in the blood or tissues any of the results of its oxidation, such as alde¬ 
hyde or acetic acid, but also because they found it unchanged in the 
expired air, the sweat, and especially in the urine. The results ob¬ 
tained by the Fx’ench investigators were, however, seriously questioned 
by E. Baudot (_Z7 Union Medicate , 1863), who demonstrated that the 
chromic acid test which Duroy and Perrin had relied on for detecting 
alcohol in the excretions is so delicate as to reveal .165 grain of alcohol 
in a quart of water; and Baudot further affirmed as the result of 
twenty experiments that, except after immense doses, the amount of 
alcohol eliminated by the kidneys is so small as practically to amount 
to nothing. In 1866 Dr. Schulinus ( Archiv der Heilkunde , 1866), by a 
very elaborate and laborious investigation, confirmed the results of 
Baudot, showing that alcohol taken into the blood finds its way by 
exosmose into all organs in similar proportion, and does not escape 
through the kidneys unless in very trifling amounts. In several ex¬ 
periments he found that one-fourth of the ingested alcohol had disap¬ 
peared from the body after from two to three and one-fourth hours, 
and, as but a fractional portion of the lost amount was eliminated, 
he concluded that it must have been burnt up. Adolph Lieben ( An - 
nalen der Ghimie und Pharmacie, 1870, vii., Supplement. Bd. p. 236) 
has in a number of experiments arrived at results similar to those of 
Schulinus. 

In 1865 a number of experiments yielded to Anstie, of London 
(Stimulants and Narcotics , (reprint) Philadelphia, 1868), similar re¬ 
sults, and also demonstrated that the elimination from the lungs is 
exceedingly trifling. Thudichum investigated the matter on a large 
scale in 1864, and again with the assistance of Dupre in 1866 ( Tenth 
Report of the Medical Officer of the Privy Council , London, 1868). In 
order to avoid the fallacies of the chromic acid test, the alcohol was 
obtained from the urine by repeated distillations. In the first instance 
forty-four bottles of wine, containing four thousand grammes of alco¬ 
hol, were drunk by thirty-three men, out of whose urine, collected 

22 


338 


GENERAL REMEDIES. 


during the next six hours, ten grammes, or only 0.25 per cent., of 
the ingested alcohol were recovered. In the experiments of 1866 the 
process was substantially the same, hut, greater care being taken to get 
absolute accuracy and to avoid loss during distillation, 0.82 per cent, 
of the amount administered was found in the urine. Professor Sub- 
botin (Zeitschrift fur Biol., vii., 1871; Schmidt's Jahrb., 1872, Bd. cliv. p. 
261) has made an apparently close experimental study of the subject 
upon six rabbits, and has shown that elimination continues for a longer 
time than had been generally believed, and that twice as much of the 
alcohol escapes by the skin and lungs as by the kidneys. In one ex¬ 
periment he found that sixteen per cent, of the alcohol escaped un¬ 
changed in the first twenty-four hours; elimination after this time, 
although perceptible, amounted to very little. As he, like Lallemand 
and his colleagues, experimented with poisonous doses, his results con¬ 
firm rather than contradict those of Baudot, Schulinus, Anstie, Thudi- 
chum, and Dupre; for it is manifestly evident that after such doses 
elimination would be proportionately greater than after smaller quan¬ 
tities, as there naturally must be a limit to the powers of the system 
to oxidize alcohol. Professor R. D. Edes, in his experiments ( Boston 
Med. and Surg. Journ., 1872, p. 347), found that after small doses the 
amount of elimination by the breath is greater than that by the kid¬ 
neys, although the contrary holds where large amounts have been ad¬ 
ministered ; in either case the total amount eliminated was but a small 
percentage of the amount ingested.* Finally, Anstie ( Practitioner , July, 
1874) has repeated his experiments, using the method of Subbotin, 
and even subjecting a dog, which had been taking for some days very 
much larger amounts of alcohol than he had eliminated by skin, kid¬ 
neys, rectum, and lungs, to distillation, with the results of confirming 
his first experiments and of finding no “ residual alcohol”— i.e., alcohol 
left in the body—worthy of mention. In an elaborate research, Dr. 
Guido Bodlander found that he himself, after the use of alcohol in 
various quantities, eliminated by the kidneys about 1.2 per cent., and 
by the lungs about 1.6 per cent; while in dogs he recovered from the 
breath about 2 per cent., from the urine 1.6 per cent., from the skin 
0.14 per cent, of the ingested alcohol. He failed entirely to find alco¬ 
hol in the intestinal excretions, and also, contrary to Lewald’s obser¬ 
vation in 1857, in the milk of a goat to which nearly a quart of brandy 
had been given (Archiv f. Physiol ., xxiii.). 

These concurrent investigations! certainly demonstrate that but a 


* Professor Edes relied upon the chromic acid test, which Binz asserts to be fallacious. 
In the experiments made by Stenbach and Schmidt, under Professor Binz’s direction, alcohol 
could not be detected in the breath, and Professor Binz believes that no elimination of it 
occurs from the lungs. He declares that the odor of the breath after drinking is not that of 
alcohol, but of the ethers and other volatile principles of the various liquids imbibed. 

f I believe these results have also been confirmed by Wohler, Journal dea Progrls, xi., 
but I have not seen the original paper or any abstract of it. 



CA RDI A C S TIM ULANTS. 


339 


small proportion of ingested alcohol is either eliminated from or accu¬ 
mulated in the body, and consequently that it must be oxidized in the 
body, and in some degrees partake of the nature of a food. It has been 
objected to this that no one has as yet been able to detect* in the blood 
any of the ordinary products of its oxidation; the probable reason of 
this is, however, that the oxidation is carried as it were at one bound 
to its ultimate end, the production of water and of carbonic acid. A 
strong corroborative proof that alcohol is largely consumed in the 
body is furnished even by the experiments of Lallemand, Duroy, and 
Perrin themselves, for they proved that elimination ceased, or at least 
could not be detected by the most delicate tests, before the alcohol had 
all escaped from the body. 

A very strong confirmation of the theory that asserts the oxidation 
of alcohol in the body is found in the researches of our countryman 
Dr. H. Ford, whose experiments have, however, not been repeated, and 
therefore, although apparently carefully performed, lack the absolute 
authority of complete confirmation. Dr. Ford ( N '. F. Med. Journ., Jan. 
1872) has worked upon the supposition that the hepatic sugar must be 
converted into alcohol in the body before its final destruction, and, 
using large quantities of blood of animals, has sought by repeated 
distillations to obtain alcohol from it.f 

Pushing his researches still further, Dr. Ford used various tissues 
as the substances to be distilled. He also made elaborate calculations, 
based on the carbon ingested and on the carbon exhaled, as to the 
amount of alcohol which ought to be found in the capillary blood of 
the lungs. The results are expressed in the following table: 


* Duchek ( Vierteljahr.f. Prakt. Heilk., Bd. iii., 1853) did not, as he thought, demonstrate 
the presence of aldehyde in the blood of animals poisoned with alcohol. 

f Space is wanting to describe in detail the very elaborate methods employed by Dr. 
Ford. The tests which he relied on, to prove that the liquid obtained was alcohol, were the 
chromic acid test, the peculiar inflammability, and the optical appearance of the alcohol in 
the conducting-tubes at the time the distillate commenced to boil. In order to prevent any 
possible oxidation of the alcohol during the process, Dr. Ford sometimes added sulphuretted 
hydrogen. The results of ten experiments are shown in the following table: 


No. 

Weight of 
Blood. 

Interval 
from 
Death to 
212°. 

Tempera¬ 
ture when 
distilled. 

Weight of 
First Dis¬ 
tillation. 

Weight of 
Final Dis¬ 
tillate. 

Weight of 
Alcohol 
obtained. 

Weight of 
Alcohol for 
10,000 parts 
of Blood. 

With or 
without HS. 

15 

6970 

60 m. 




0.0650 

0.0932 

without. 

16 

9734 

56 

101° 

1602 

0.8416 

0.0198 

0.0203 

without. 

17 

9137 

70 

100.3 

1636 

1.6218 

0.0605 

0.0662 

with. 

18 

9236 

77 

99.5 

1623 

3.6130 

0.0444 

0.0480 

with. 

19 

8988 

60 

99 

1555 

2.6092 

0.1357 

0.1509 

with. 

20 

8854 

60 

98 

1555 

1.7320 

0.0760 

0.0858 

with. 

21 

9423 

45 

96 

1560 

1.8722 

0.0708 

0.0751 

without. 

22 

9112 

61 

98 

1550 

0.9552 

0.0350 

0.0384 

without. 

23 

27330 

48 

98 

14050 

10.6883 

0.2928 

0.1071 

with. 

24 

36300 

51 

99 

17600 

14.0606 

0.5652 

0.1556 

with. 























340 


GENERAL REMEDIES. 


Alcohol in the capillary blood of the lungs: 

j calculation based on carbon ingested . . 0.5403 

1 “ “ “ carbon exhaled . . 0.5794 

“ putrescent lung-tissue (mean of exp. 8, 9, and 11) . 0.3819 

u fresh “ ( “ “ 12, 13, and 14) . 0.3076 

“ putrescent thoracic blood (mean of exp. 1,2,3,4, and 5) 0.7625 
“ fresh “ “ (mean of table) . . . 0.0841 

“ putrescent liver-tissue (exp. 6).4.3138 

“ fresh “ (mean of exp. 25, 26, and 27) . 0.0190 

The important facts seemingly established in the above table are; 
the correspondence between the amount of alcohol in the thoracic 
blood as obtained by calculation and by experiment; that the smallest 
quantity of alcohol is to be obtained from fresh liver-tissue, and the 
greatest from putrescent liver-tissue, in which the glycogen must have 
undergone fermentation. The fresh thoracic blood was blood which 
had not traversed the lungs; the putrescent thoracic blood of course 
represented the same blood with all its sugar fermented. 

These researches of Dr. Ford are certainly corroborated by the dis¬ 
covery, first made, I believe, by A. Lieben ( Annalen d. Chem. Pharm., 
1870), although usually attributed to Dupre ( The Doctor , Feb. 1 , 1873), 
that a substance exactly resembling alcohol exists in very minute quan¬ 
tity in the urine even of teetotalers.* M. Bechamp ( Lancet , 1873), ap¬ 
parently without a knowledge of the work of the other chemists, ob¬ 
tained, from the urine of persons who had not taken any alcoholic 
beverage for a long time, alcohol in sufficient quantity to burn it. As 
Lieben also found that this substance exists in the urine of dogs, horses, 
and lions, and as A. Rajewski obtained it from healthy rabbits ( Archiv 
fur Physiologie , xi. 122, 1875), its existence in the normal organism must 
be considered demonstrated. 

Upon the nervous system alcohol exerts a powerful influence. Its 
effects upon the cerebrum are too well known to require elaboration; 
but it may be mentioned that I. Dogiel (loc. cit.) has found that in frogs 
the reflex susceptibility is at first somewhat, and afterwards decidedly, 
diminished by large doses of alcohol, and that the sensory and motor 
nerves are similarly affected. 

The question of the effect of alcohol upon digestion is an important 
one. There can be no doubt that very large doses hinder digestion. 
According to the experiments of W. Buchner ( Deutsch. Arch. f. Klin. 
Med., xxix. 537), ten per cent, of pure alcohol does not affect artificial 
digestion, while beer, even diluted, retards it. The use even of small 


* It is asserted that the substance “ is not alcohol. It passes over among the earliest 
products of distillation, yields acetic acid on being oxidized, reduces the bichromate of potas¬ 
sium when dilute sulphuric acid is present, and its aqueous solution has a lower density than 
water. It furnishes iodoform, and exists in the urine in a very small quantity.’' Possessing 
the physical and chemical characters of alcohol, to ordinary minds it is alcohol. 



CARDIAC STIMULANTS. 


341 


doses of alcohol seemed to delay digestion in a few experiments made 
by washing out the stomach a fixed time after a meal taken sometimes 
with, sometimes without, alcoholic drink. The method is, however, too 
crude to allow much weight to the experiments; for it is possible that 
alcohol may lessen the rapidity with which the food leaves the stomach, 
and therefore aid in the thoroughness of gastric digestion. Certainly 
every-day experience teaches us that in small amounts wines and liquors 
enable the bon vivant to digest more than is natural or proper. 

From what has been said, it is certainly deducible that alcohol in 
small amount is an arterial and cerebral stimulant , increasing functional 
activity in the nervous and circulatory apparatus; that it is a food , 
in the sense that it is destroyed in the system and yields force which is 
utilized by the organism; and that it is, when in sufficient quantity, a 
retarder of tissue-changes, checking the excretion of nitrogen. 

If alcohol be oxidized in the body, and be a food, as it seems to 
me is clearly proved, it must of course generate force, measurably by 
the modern standard of the heat-unit. A little calculation will show 
the importance, or rather the great amount, of the generated force. 
According to Dupre ( Practitioner , 1872, vol. ix. p. 33), one gramme 
of alcohol oxidized in the body evolves 7184 units of heat, while the 
same weight of lean beef gives off only 1482 units of heat. It has 
been estimated that 9.3 ounces of lean beef—equal to about two ounces 
of alcohol—will supply the necessary force to maintain the circulation 
and respiration of an average man for one day. That is, four ounces 
of strong spirit will suffice for this purpose. Since to the ability of 
furnishing material whose consumption shall give power is added the 
ability to restrict waste and to stimulate the functions of circulation 
and of the nervous system, it is evident that in alcohol we have a most 
important means of sustaining the system during the strain of an acute 
exhausting disease. 

Therapeutics. —Our knowledge of the physiological properties of 
alcohol shows that its chief therapeutic value in acute disease is as a 
stimulant, a temporary imparter of power which shall enable the system 
to stand some strain of like duration,—to bridge over some period of 
weakness. 

The cases to which it is especially adapted may be divided into three 

classes: 

First. Those in which there is a temporary loss of heart-power, as 
in fainting from exhaustion, loss of blood, or other cause. In these 
cases the alcoholic stimulant should, if possible, be given hot, and not 
much diluted; with it should also be exhibited some more rapidly acting 
diffusible stimulant, such as ammonia. 

Second. Those acute diseases in which the powers of the system are 
in danger of being used up; to aid in the digestion of food and in the 
maintenance of power. Alcohol, as has already been stated, is to a cer¬ 
tain extent a food, but it will not of itself sustain life for a long time, 


342 


GENERAL REMEDIES. 


and should in adynamic disease always, unless for special reasons, be 
combined with milk, or occasionally with eggs. One great source of 
its value in these diseases is the power it imparts of assimilating food, 
and in milk-punch are furnished the stimulant to digestion and the most 
perfect food known for digestion. This use of alcohol is apart from its 
office in the lowest stage of fever as a heart- and nerve-stimulant. 
Employed for this purpose it is useful in all stages of the adynamic 
fevers , such as typhus and typhoid. By the exhibition of three or four 
ounces of milk every two hours, with one or two drachms of brandy 
or whisky, from the beginning of the attack, in many cases the de¬ 
velopment of the severe adynamic symptoms may be prevented. 

In the advanced stages of diseases, when the typhoid state is well 
developed, alcohol should be given boldly,—to quiet by stimulation the 
nervous and circulatory systems,—to afford a food which shall in a 
measure replace the natural pabulum,—to aid in the digestion of milk 
and other simple nourishment,—to aid in lowering temperature by 
checking the tissue-waste of fever: in a word, to enable the system to 
stand the drain upon its vital powers, and at the same time to check 
such drain. 

Properly administered, it always promotes, not arrests, secretion in 
these cases. The guide to the amount given should be the effects pro¬ 
duced : so long as it lowers temperature and pulse-rate, moistens the dry 
tongue and skin, and quiets the nervous disturbance, it does good; if, 
however, the tongue grows drier, the pulse puts on an angry, bound¬ 
ing character, and the patient becomes restless and uneasy, stimulation 
is being pushed too far, and the amount exhibited should be lessened. 
Whenever the odor of liquor appears upon the breath , the patient is 
almost certainly taking too much. 

The antipyretic action of alcohol has suggested its use in cases of 
high temperature; as, however, this is only one of its actions, and as it 
is not decided unless very large doses be given, alcohol cannot be em¬ 
ployed as a general febrifuge. True arterial excitement and sthenic 
inflammation certainly contra-indicate its use. The rule may be laid 
down as follows: high temperature is an indication for the use of alco¬ 
hol only when other symptoms also demand it; in itself high tempera¬ 
ture is never a contra-indication to alcohol. In acute sthenic diseases , 
after the progressive stage has passed and the results of the disease 
simply remain to be overcome, alcohol and milk will often save life. 
Thus, in acute pneumonia , when so much consolidation has occurred as 
to render it doubtful whether the exuded matter can be removed, or in 
abscess, when large amounts of pus have formed, the demand may be 
very great for alcohol as a food and as an aider of digestion, and 
sometimes as a stimulant. 

Third. Those in which there is a depressing agent. In many 
forms of poisoning , alcohol may be used with signal advantage simply 
as an arterial and nervous stimulant, to overcome the influence of a 


CARDIAC STIMULANTS. 


343 


depressing agent. Thus, in snake-bite the unlimited use of it affords, 
with the hypodermic use of ammonia (see Ammonia), the best method 
of treatment. It has been very strongly recommended in pyaemia by 
Dr. Theodor Clemens, of Frankfort (. Deutsche Klinik , 1874, 1875), who 
states that he has seen eight cases of a severe type recover under 
the administration of red wine in as large amounts as the patient 
would drink. In poisoning by aconite , veratrum viride , or other similar 
substance, where death is threatened through failure of the heart- 
power, alcohol in some form is imperatively needed. In all these cases 
of acute depression threatening a fatal issue, it should be administered 
freely, not much diluted, and, if convenient, hot. From one to four 
ounces of whisky should be given, repeated every ten or fifteen min¬ 
utes, until slight intoxication, convalescence, or death has resulted. 

What has been said up to this point in regard to the therapeutic 
action of alcohol has had reference to acute disease. The value of the 
drug in some chronic diseases cannot be doubted; but in prescribing it 
the physician should never lose sight of the possible danger of pro¬ 
ducing a habit far worse in its fruits than death itself. 

In chronic neuralgia , in hypochondriasis , in melancholia , temporary 
relief may sometimes be obtained by the use of stimulants ; but the 
very relief afforded doubles the temptation to the frequent use of the 
alcohol, and, as the system becomes habituated to its action and the 
dose has to be more and more increased, the habit of frequent stimu¬ 
lation grows almost of necessity into drunkenness. For this reason I 
do not think the physician is ever justified in prescribing alcohol for 
its narcotic stimulant effect in these cases. The chief legitimate uses 
of alcohol in chronic diseases are to aid in digestion, to furnish a food 
which, without any digestive effort upon the part of the system, shall 
be absorbed and shall take the place of more ordinary food, and to 
check excessive tissue-waste. Of course these indications exist only in 
such diseases as are either dependent upon or closely associated with 
a condition of system in which the general nutrition is depraved. In 
purely local affections the use of alcohol is rarely called for except in 
the last moments of life, when it may always be employed to afford 
relief and to protract for a short time the struggle. In chronic dyspepsia , 
alcohol administered with the food often aids very materially in the 
assimilation of the latter; but care has to be exercised in prescribing 
it, for the same reasons as were given when speaking of the use of 
stimulants in melancholia a moment since. In many cases of chronic 
neuralgia , not as a narcotic stimulant, but as a food and a stimulant 
to nutrition, alcohol is often of the greatest service. The danger of 
establishing a fatal habit in this disease is, however, excessive. In 
almost all cases in which alcohol is called for in neuralgia, cod-liver oil 
is also indicated, and it is generally best to exhibit the two remedies 
together, so as to obtain the easy assimilation of the oil and to guard 
against evil moral results. 


344 


GENERAL REMEDIES. 


In phthisis and its congener scrofulosis, there can be no doubt as to 
the great value of alcohol ; and in the latter stages of consumption its 
judicious use as an antipyretic narcotic stimulant to lessen the suffer- 
ings of the patient is perfectly justifiable. During the chronic move¬ 
ments of the affection, alcohol taken with cod-liver oil, or in small 
amounts with the food at meal-times, conduces not so much to the 
comfort as to the well-being and recovery of the patient. 

The question as to the propriety of the daily use of alcohol by 
healthy men is at present a very serious one, involving so many moral 
and politico-moral issues that it cannot be fully discussed here. Suf¬ 
fice it to state, as obvious inferences from our present knowledge of 
the physiological action of alcohol, that the habitual use of moderate 
amounts of alcohol does no harm; that to a certain extent it is capable 
of replacing ordinary food, so that if the latter be scanty, or even if it 
be coarse and not easily digested, alcohol, in some form or other, is of 
great advantage; that in all cases it should be taken well diluted, so as 
not to irritate the stomach ; and that wine or malt liquors are certainly 
preferable to spirits. The experience of Arctic explorers has clearly 
shown that alcohol has no heat-producing power, so that at a time when 
it was believed to have such influence by physiologists the Northern 
navigators had learned that the free use of spirits, far from enabling a 
man to withstand habitual exposure to intense cold, very materially 
lessened his power of resistance. On the other hand, the experience 
of almost every trout-fisherman or sportsman has satisfied him that 
spirits do have power to prevent “ catching cold” under sudden and 
unaccustomed exposure to wet and cold, and that benumbed extremities 
will become warm and have their proper feelings return under the 
influence of a glass of whisky. There is, however, nothing strange or 
contradictory in these experiences, and they are both in strict accord 
with our present knowledge of the physiological action of the drug. 
As is often the case, the facts were practically made out, however, 
before science could solve the apparent paradox. It has been abun¬ 
dantly shown that alcohol has no heating power; but the chill of sud¬ 
den exposure, the suffering benumbed extremities, the bronchitis that 
perhaps follows, all mean simply this : that, as a result of the cold, the 
blood leaves the surface and the extremities, the circulation fails in the 
outposts, and, as a consequence, suppressed perspiration— i.e ., suspended 
function of the skin—and internal congestions follow. The relief af¬ 
forded by the spirits, as well as the prevention of sickness, is due 
simply to the power of the remedy in maintaining the circulation and 
keeping the external surfaces warmed by the constantly-renewed cur¬ 
rents of fresh blood from the interior of the body. 

Owing to its stimulant and antiseptic properties, alcohol constitutes 
an excellent dressing for wounds, whether accidental or surgical in their 
origin. It would seem also to lessen pain by a local anaesthetic effect 
(Horvalle, Gaz. des Hopitaux , Sept. 1878). Strong surgical testimony 


CARDIAC STIMULANTS. 


345 


as to the local value of whisky has been given by Drs. Blair ( Glasgow 
Med. Journ., Feb. 1870) and Suesserott ( Phila. Med. Times , vol. iv. p. 
774). Lint soaked and kept constantly wet with spirits is to be packed 
on or in the wound. 

Administration. —Almost enough has been already said upon this 
point; but a few further remarks seem appropriate. When stimulants 
are used to sustain the sinking powers in poisoning or in disease, the 
amount given should be almost solely regulated by the effects. Thus, 
in snake-bite it may be necessary to give a pint of whisky in the course 
of an hour; and in low fevers I have seen the greatest benefit result, 
and life apparently saved, by the exhibition of a quart of spirits a day. 
The rule is always to be governed by the effects. In poisoning, one, 
two, three, or four ounces, as the case may seem to need, should be 
exhibited every ten minutes until some effect is produced or matters 
become hopeless. In low fevers half an ounce to an ounce should be 
given every one, two, or three hours, pro re nata , the practitioner 
watching the results, as already spoken of. 

The question of choice, of course, comes up in every case as to 
which of the spirits shall be used. I have never been able to perceive 
any difference in their action (gin, of course, being excepted), save only 
that sometimes one agrees better with the stomach than another. 
This has seemed to me to depend simply upon the personal likings of 
the patient, to which therefore the choice may well be left. In sudden 
collapse, some of the wines with a very high bouquet are believed to be 
more stimulating, on account of the ethers which they contain; but I 
have had no experience with them. In convalescence, and for habitual 
use in health, wines are preferable to spirits,—more agreeable, more 
tonic, and less apt to lead to excessive indulgence. 

When a mild stimulant is wanted in the beginning of fevers, es¬ 
pecially if milk punch seems too “ heavy,” wine whey may be sometimes 
used with advantage. It is made by pouring a half-pint of sherry or 
madeira into a pint of boiling milk, stirring thoroughly, and, after 
coagulation has occurred, straining off the whey, which may or may 
not be sweetened, according to the taste of the patient. Mulled wine is 
often very grateful to patients as a change. It is made by beating an 
egg up thoroughly with three fluidounces of sherry and adding a like 
quantity of water, which must be actually boiling when poured in. 
Champagne is useful in patients with delicate stomachs, especially if 
nausea or vomiting actually exists, and also may be employed with 
advantage in sudden failure of the vital powers, especially in elderly 
persons. It must always be very “ dry,”— i.e., as free as possible from 
sugar. 

Milk punch is prepared by adding from a dessertspoonful to a fluid- 
ounce of brandy, whisky, or rum, according to the degree of stimula¬ 
tion required and the taste of the patient, to three fluidounces of milk, 
with sugar and nutmeg to taste. The addition of a tablespoonful of 


346 


GENERAL REMEDIES. 


lime-water is not recognized by the palate, and renders the beverage 
more acceptable to the stomach when the latter is weak. 

Egg-nog is still more nutritious than milk punch, but is “ heavier,” 
and is usually rejected by the stomach if given too freely. It is made 
by beating up thoroughly the yelk of an egg with five fluidounces of 
milk and half a fluidounce to one fluidounce of spirits (and half a 
fluidounce of lime-water if required), and adding a sufficiency of sugar, 
with finally the white of the egg previously thoroughly beaten into a 
froth. 

Toxicology. —The acute form of alcoholic poisoning in its minor 
degrees is, unfortunately, an hourly occurrence almost in every village, 
but that fatal results are not absolutely so rare as is generally believed 
is shown by the fact mentioned by Taylor, that in four years (1863-67) 
thirty-five deaths from this source occurred in England and Wales. 
It is worthy of note that in some fatal cases convulsions have preceded 
death ( Phila. Med. Times, vi. 463). The absolute diagnosis of acute alco¬ 
holic poisoning when the patient is simply seen in the advanced stage 
of deep coma cannot be made out. The odor of liquor upon the breath 
or about the person is simply a jn’oof that the subject has been drink¬ 
ing, not that the symptoms are caused by alcohol. The manifestations 
are merely those of profound compression or congestion of the brain, 
of apoplexy, of opium-poisoning; and a man who has been drinking 
only moderately may have been struck down with apoplexy or poisoned 
with opium. Dr. Hughlings Jackson has recorded a case in which the 
alcohol impregnated not only the breath but the urine also, and in 
which the patient was left to sleep it off; but at the post-mortem a 
clot was found covering nearly the whole of one hemisphere. After 
death in acute alcoholic poisoning the stomach is found very much 
congested, and sometimes ecchymosed. The treatment consists in the 
evacuation of the stomach, the use of the alternate hot and cold douche, 
and the usual mechanical methods of arousing a narcotized patient. 

DIGITALIS. U.S. 

The leaves of the Digitalis purpurea, or foxglove, of the second 
year’s growth. These are large leaves, of a dull pale green, with 
whitish doAvn underneath, and have a bitter nauseous taste and a 
faint narcotic odor. Digitalis yields both to water and to alcohol. M. 
Homolle obtained from digitalis many years ago a peculiar bitter sub¬ 
stance, which was believed to be the active principle, and was officinal 
in the United States Pharmacopoeia under the name of digitalin ( Digi - 
talinum). As prepared according to the directions of the United States 
Pharmacopoeia of 1860, it is a whitish or yellowish powder, odorless, 
but of a very bitter taste, nearly insoluble in ether and in water, readily 
soluble in alcohol and in acids. With hydrochloric acid it makes a yellow 
solution, which soon changes to green. This substance, commonly known 
as French digitalin , differs from the German digitalin of commerce in 


CARDIAC STIMULANTS. 


347 


being in great part or entirely soluble in water. It is a complex body, 
and does not entirely represent the medical properties of digitalis. As 
kept in the drug-stores, digitalin varies both in strength and in medical 
properties, and at the 1870 revision of the United States Pharmacopoeia 
it was very properly dropped. In 1871, M. Nativelle announced ( Bul¬ 
letin de VAcad. Roy. de Medecine, 1871, vol. xxxvi.) to the Academy of 
France that he had discovered a process by which a crystallized sub¬ 
stance could be prepared from digitalis, and received the grand prize 
of Orfila. 

Crystallized digitalin (Journal de Chimie Medicate , 1873) occurs “in 
short and delicate needle-shaped crystals, and possesses an intense and 
persistent bitter taste. It is but slightly soluble in water, soluble in 
twelve parts of cold and six of boiling alcohol of 90°, less soluble in 
absolute alcohol, and nearly insoluble in ether; very soluble in chloro¬ 
form. It is rapidly dissolved by a solution of chloral hydrate, the solu¬ 
tion becoming greenish blue in color. The concentrated mineral acids 
dissolve it, hydrochloric acid producing an emerald-green color, sul¬ 
phuric acid a green which if subjected to the action of bromine fumes 
changes to a dark red, nitric acid a yellow, nitro-muriatic acid a yellow 
changing to an obscure green, and a mixture of equal parts of sul¬ 
phuric and nitric acids a rose-color changing to a deep violet. When 
heated on platinum, it melts, swells up, becomes brown, and disappears 
without leaving any traces. It contains no nitrogen, but is composed 
of 51.33 per cent, of carbon, 6.85 per cent, of hydrogen, and 41.82 per 
cent, of oxygen.” 

According to Ch. Blaquart (L' Union Pharmaceutique, Nov. 1872), 
ten per cent, of crystallizable digitalin can be extracted from the crude 
drug, which probably contains twelve per cent, of it. The question 
whether this substance is the pure active principle of digitalis is, of 
course, an important one. The French commission reported as the 
result of physiological experiments that it produces in man and ani¬ 
mals effects similar to those of the amorphous digitalin, but that it is 
much stronger than the latter. This conclusion has, however, met 
with some opposition. M. Gubler ( Bulletin de VAcad. Roy. de Medecine , 
vol. xxxvii. p. 404) denies that this crystallized digitalin is stronger 
than the amorphous preparation, and M. Yulpian in the subsequent 
discussion asserted that in experimenting he had found them of equal 
strength, and Ch. Blaquart (loc. cit .) in his experiments arrived at a 
similar result; yet one-ninth of a grain of it is said to have been given 
to an adult without causing a toxic effect.* Megerand and Daremberg 
(London Medical Record , 1873, p. 278) have found the crystalline variety 
the stronger. Dr. Boucher affirms ( Gazette Medicate , 1874) that the 
crystallized digitalin is readily convertible into the amorphous or gran¬ 
ular variety; but he also asserts ( Les Mondes , July, 1872) that it is a 


* For the process of manufacture, see Boston Medical and Surgical Journal, p. 35, 1873. 



348 


GENERAL REMEDIES. 


complex body.* This assertion is confirmed by several chemists, 
especially by O. Schmiedeberg ( Archiv fur Experiment. Pathologie und 
Pharmakol., Bd. iii. p. 19), who affirms that there are in digitalin four 
active principles: Digitoxin, the most active of all, which constitutes 
the greater bulk of Nativelle’s crystallized digitalin; Digitalein; Digi¬ 
talin ; and Digitonin. f For a particular account of these substances the 
reader is referred to the paper of Schmiedeberg. | The only practical 
conclusion at present possible is, that it is best to use only officinal 
preparations, such as the tincture, which represent the crude drug.§ 

Physiological Action.— To the therapeutist the interest in the 
physiological action of digitalis centres chiefly upon the circulation. 
The drug does, however, exert a direct influence upon the apparatus 
of voluntary motion which is worthy of notice. In toxic doses it 
lowers reflex activity, and induces lassitude, prostration, muscular 
tremblings, and sometimes convulsions. That the muscles themselves 
are affected has been proved by the researches of Yulpian, of Dyb- 
kowsky and Pelikan, and of Gourvat, all of whom have found that 
the muscles of frogs poisoned with digitalis respond more feebly than 
is normal to galvanic currents. The nervous tissue has, however, been 
found by Gourvat to be more susceptible than the muscular, the nerves 
losing their functional power sooner and more completely than the 
muscles. 

As the result of an elaborate experimental study ( Reichert's Archiv 
fur Anatomie, 1871, p. 252), Dr. A. Weil concludes that digitalis first 
lessens reflex activity by directly— i.e., independently of its action on 
the circulation—exciting the inhibitory reflex centres of Setschenow, 
and after a time by directly paralyzing the spinal cord. The experi¬ 
ments upon which this conclusion was based are divided into two 
series, in the first of which it was found that after small toxic doses of 
the poison great diminution in the reflex activity of the frog was ap¬ 
parent in from ten to twenty minutes, and continued until the death of 
the batrachian, but that this diminution for from twenty-five minutes 


* G. Bouchardat {Bull. Therap., xc. 81) calls attention to the fact that crystallized digi¬ 
talin does not, and amorphous digitalin does, polarize light. 

f Digitaliresin and digitoxiresin are derivatives respectively from digitalin and digitoxin 
of Schmiedeberg. A study of their physiological action may be found in Arch. f. Exper. Path, 
u. Pharm., Bd. iv. p. 191. 

J Consult also Schmidt’s Jahrbricher, Bd. clviii. p. 234, for abstract of thesis by Nicolai 
Gorz, of Dorpat. 

£ Digitonin is asserted to form the bulk of the soluble digitalin of commerce, and to be 
the same as saponin, the active principle of soap-bark. As saponin has been apparently 
demonstrated to he the physiological antagonist of digitalis, it is evident that the whole mat¬ 
ter is exceedingly confused, and that the conclusion in the text is the only one that can at pres¬ 
ent be reached. P. H. Laffon, as the result of experiments made chiefly on dogs, comes to the 
conclusion that the crystallized digitalin of Nativelle, the amorphous digitalin of Homolle, 
and the German digitoxin have similar toxic properties. He denies that digitalin is ever 
eliminated by the kidneys, having always failed to find it in the urine. {Annales d’Hrjgihre, 
xvi. 506.) 



CARDIAC STIMULANTS. 


349 


to an hour was immediately suspended by section of the cord high up, 
the reflex activity returning at once to its normal state; that after 
large doses the reflex movements were almost abolished in five minutes, 
and continued until death, but at any time during the first ten or 
twenty minutes could at once be restored by section of the upper 
cord; and that, both after large and after small toxic doses, a time 
finally came when division of the cord had no power to restore the lost 
reflex functions. These experiments have been confirmed by Dr. Mei- 
huizen ( Arch. f. Physiol ., vii., 1873). The second of Dr. Weil’s series of 
experiments were directed to discovering whether the action upon the 
inhibitory reflex centres and the cord was a direct one, or was simply 
the result of the altered circulation. In this part of the investigation, 
the hearts of frogs were cut out, or their motion arrested by the local 
application of a concentrated solution of nitrate of potassium, or ren¬ 
dered slower by a dilute solution of the same salt, and the effects of 
these various procedures upon the reflex activity were studied. It was 
found that slowing of the heart’s action did excite the Setschenow’s 
centre, but not to nearly so great an extent as did digitalis, and that 
minute doses of digitalis sometimes stimulated the Setschenow’s gan¬ 
glion and lowered reflex activity before the heart was sensibly affected. 
In regard to the spinal cord it was proved that when the heart was 
killed by the local action of potash the reflex functions of the spinal 
ganglia remained intact for a much longer period than when digitalis 
was administered. 

Circulation. —The action of digitalis upon the heart of the frog was, 
I believe, first investigated by M. Yulpian ( Comptes-Rendus de la Soc. 
de Biol., 1855, p. 70), who has been followed by numerous observers, 
among whom may be mentioned W. Dybkowsky and E. Pelikan (Zeit- 
schrift fur Wissenschaft. Zoologie, Bd. xi., 1862), A. B. Meyer ( Arbeiten 
aus dem Physiologischen Institut zu Zurich, quoted by Boehm), Legros 
and Legroux (quoted by Gourvat), Claude Bernard (quoted by Gourvat), 
Rudolf Boehm ( Pflilger's Archiv fur Physiologic, Bd. v., 1872), Homolle 
(.Archives Generates de Medecine, July, 1861), Gourvat (Gazette Medicate 
de Paris, 1871), Fothergill ( Digitalis, London, 1871), Fagge and Steven¬ 
son (Trans. Roy. Soc., London, vol. xiv.), J. F. Williams (Arch. f. Exper. 
Path. u. Pharrn., xiii. 1), and II. F. Gaskell (Journ. of Physiol., iii. 48). 

The statements of these investigators agree in all essential points. 
One or two of them have occasionally noted a primary brief accelera¬ 
tion of the heart’s action; but the rarity of its occurrence shows that 
it has been probably produced by some extraneous unnoted influence. 

The first distinctive action of the drug is a marked lessening of the 
number of cardiac beats per minute, due to a prolongation of the dias¬ 
tole, which may be complete, but is more generally divided by an abor¬ 
tive attempt at ventricular contraction. The systole is abnormally 
energetic, so that the ventricles become white as the last drop of blood 
is squeezed out of them. As the action of the drug becomes more 


350 


GENERAL REMEDIES. 


intense, the rhythm of the heart is very much affected, the ventricle 
and auricle no longer beating in accord. At the same time the diastole 
generally becomes imperfect, one portion of the ventricle maintaining 
its systolic spasm, while the rest dilates. Thus, the extreme apex may 
remain hard and white during the diastole, and even hernial protru¬ 
sions of the ventricle may occur. Finally, the heart is arrested in 
systole; and as the muscle so hardens, of course all its power of re¬ 
sponding to electrical or other excitants is lost. 

In some rare instances, instead of the above series of phenomena, 
the diastolic periods throughout are prolonged and quiet, and after 
several periods of relaxation, lasting for ten or twenty seconds, final , 
diastolic arrest may occur. 

As both Boehm {op. cit., p. 163) and Dybkowsky and Pelikan (loc. 
cit .) have found that the slowing of the heart’s beat, the increased 
energy of contraction, and the irregularity and final systolic arrest are 
produced by digitalis after division of the vagi and destruction of the 
spinal cord, and as both Ackermann (quoted by Boehm, op. cit., p. 158) 
and Boehm have found that the paralyzing of the peripheral ends of 
the vagi by atropine does not prevent the phenomena just alluded to, it 
is evident that the drug acts directly upon the heart-muscle itself, a 
conclusion which is confirmed by Eulenburg and Ehrenhaus (quoted 
by Dr. T. Lauder Brunton, On Digitalis , London, 1868, p. 51), who 
found that digitalis, when locally applied, acts at once upon the heart. 
On the other hand, the inhibitory activity of the peripheral ends of 
the pneumogastrics is without doubt increased by the drug. There is 
no stage in which stimulation of the vagi does not cause diastolic 
arrest. Indeed, Dybkowsky and Pelikan have seen galvanization of 
nerves produce such relaxation in the auricles after the ventricles had 
already become permanently contracted. Further, Boehm has found 
that a stimulation of the pneumogastrics which is insufficient to make 
itself felt before poisoning will, after the exhibition of digitalis, cause 
diastolic arrest lasting for many minutes. 

It appears, therefore, that the peripheral cardiac inhibitory appara¬ 
tus shares in the stimulant action of digitalis; and as Boehm has found 
that diastolic arrest never takes place in frogs poisoned with the drug, 
after section of the vagi, it is probable that this rare mode of death is 
really due to super-excitation of the inhibitory cardiac nerves. 

Rudolf Boehm {op. cit., p. 170) has investigated the influence of 
digitalis upon the working power of the heart when freed from all con¬ 
nection with the central nervous system. By using the method of 
Ludwig and Coats, he found as a constant result that the amount of 
work done was increased by small doses of digitalis; that after large 
doses a similar increase was followed in a short time by very great 
diminution in the expenditure of power by the heart, a diminution 
apparently due to imperfect diastole and consequent non-admission of 
serum into the viscus. By direct experiment with an artificial circula- 


CARDIAC STIMULANTS. 


351 


tion Dr. Williams has proved that the cut-out frog’s heart actually puts 
out much more force than normal under the influence of digitalis. Dr. 
Williams believes that the increased work of the heart is largely de¬ 
pendent upon an altered tone of the muscle, producing a more complete 
diastolic enlargement of the ventricles. That the systolic arrest of the 
heart by digitalis is not of the nature of a paralysis but of a spasm is 
indicated by the fact that there are various paralyzing drugs which, 
applied to the contracted heart, will cause it to recommence its beat 
(Schmiedeberg, Beitr. z. Anat. u. Physiol., Festgabe, A. Ludwig). The 
experiments of Frangois Frank upon the isolated apex of the heart 
appear to show that it is upon the muscle rather than upon the intra- 
cardiac ganglia that digitalis acts ( Journ. de Med. de Bordeaux , xi. 67).* 

The elaborate experiments of L. Traube ( Gesammelte Beitrage zur 
Pathologie und Pliysiologie, Bd. i., Berlin, 1871) upon warm-blooded 
animals showed that in dogs moderate doses of digitalis produce in¬ 
creased arterial pressure, with lowering of the rate of the cardiac pul¬ 
sation. When toxic doses were used, these phenomena were followed 
by increase of the pulse-frequency and fall of the arterial pressure, 
which, however, did not commence at the same time, since the maxi¬ 
mum pressure was not reached until the pulse had risen above the 
original, normal point. 

The experiments of Boehm, Brunton ( loc. cit .), Gourvat (loc. cit.), 
and Kaufmann on soluble digitalin {Rev. de Med., iv.), are in accord 
with those of Traube: so that it may be considered proved that in 
mammals moderate doses of digitalis produce rise of arterial pressure 
with diminished pulse-rate. 

Professor L. Traube has found that, after section of the vagi, digi¬ 
talis is in warm-blooded animals, with rare exceptions, incapable of re¬ 
ducing the pulse-rate, and, contrariwise, that when the pulse-frequency 
has been reduced by the drug, section of the nerves causes an imme¬ 
diate and very marked rise in the rate of pulsation. I believe Boehm f 
has experimentally confirmed this, as have also Kaufmann and Gourvat. 

It has been suggested that the slowing of the pulse is due simply 
to the increased arterial pressure, but Kaufmann (loc. cit., p. 389) has 
noticed the slowing of the pulse without rise of the arterial pressure, 
and it appears to me demonstrated that digitalis stimulates the cardiac 
inhibitory nervous apparatus. The experiments of Kaufmann seem to 
show that in mammals there is not at any time under the influence 
of digitalis an increased susceptibility of the peripheral vagi; and it is 
probable that it is the intra-cardiac inhibitory centres rather than the 
fibres of the vagi which are acted upon. The occasional reduction of 


* In apparent opposition to all this older evidence are the researches of Messrs. Donald¬ 
son and Stevens {Journ. of Physiology , iv.). For an elaborate discussion of this paper, and 
for the reasons why I do not think it should change our views, see editorial in Therap. Gaz., 
February, 1885. 

t His language is such as to leave the point somewhat doubtful. Op. cit., pp. 188, 189. 



352 


GENERAL REMEDIES. 


the heart-beat in warm-blooded animals by digitalis after section of the 
vagi (Traube, Kaufmann) shows, however, either that the inhibitory 
nerves in some animals find another path than the pneumogastrics, or 
else that there is an additional—sometimes inoperative, sometimes effi¬ 
cient—cause of the reduction of the pulse-rate. As it has been shown 
that digitalis is capable of slowing the beat of the isolated heart of the 
frog, it probably exerts a similar influence at times, in mammals, upon 
the cardiac muscle or its inhibitory ganglia. 

Although digitalis does increase the muscular energy of the heart, 
it seems scarcely possible that the enormous rise of pressure produced 
by it can be owing to this alone. This a priori reasoning has received 
experimental confirmation from Malan,* Fothergill ( loc. cit.), Gourvat 
( loc. cit.), Ackermann ( Ueber die Wirkungen der Digitalis , in Volkmann's 
Sammlung Klinischer Vortrage , No. 48, Leipsic, 1872), and Boldt ( In¬ 
augural Dissertation , Schmidt's Jahrbucher, March, 1872). The first 
three of these investigators have found that the arterioles of the frog’s 
web as seen under the microscope undergo very decided contraction 
after the systemic use of digitalis; and Ackermann states that if the 
abdomen of a rabbit be opened so as to expose the arteries of the 
mesentery, a very marked contraction, even to the partial obliteration 
of the lumen of the vessels, can be readily seen to follow the exhibition 
of digitalis. 

Boldt experimented upon curarized frogs after the manner of Cohn- 
heim, and found that the first effect of the digitalis was marked con¬ 
traction of the arterioles. 

It is stated by Kaufmann that in the latter stages of digitalis-poison¬ 
ing the peripheral vagi are paralyzed so that galvanic stimulation of 
their trunks is powerless to affect the heart. This appears to be in 
opposition to all previous observations, and therefore must be confirmed 
before acceptance. 

According to Boehm, Traube found that, if the spine be divided, 
digitalis is powerless to increase the arterial pressure, although lessen¬ 
ing, as usual, the pulse-rate. The same authority also states that Be- 
zold has seen an excessive fall of the arterial pressure ensue immediately 
upon the division of the spinal cord in an animal under the influence 
of digitalis. Further, in his own experiments Boehm has attained 
similar results, or, in other words, has found that after separation of 
the small vessels from the vaso-motor nerve-centre, digitalis does not 
increase arterial pressure. 

These experiments would seem to prove that digitalis acts upon the 
vessels by stimulating the vaso-motor centres in the base of the brain; 
but they have been contradicted by Ackermann ( op. cit., p. 397), who 
states that he has many times cut the spinal cord and without excep¬ 
tion found a very marked rise of arterial pressure follow the injection 


* Quoted by Fothergill (op. cit.). 



CARDIAC STIMULANTS. 


353 


of digitalis. Unfortunately, none of these experiments have, that I 
am aware of, been published in detail, and it is therefore impossible 
to analyze or to reconcile them; but Gorz ( Schmidt's Jahrbucher , Bd. 
clviii.) expresses the opinion that Ackermann did not fully divide the 
cord in his experiments. Gorz himself found that a rise is produced 
by digitalin after division of the cord, but of so small an amount as to 
be readily accounted for by the increased power of the heart.* It is 
exceedingly probable that Gorz’s explanation is correct; moreover, it 
is possible that the cord in these cases was not entirely cut. I have 
found by actual experiment that a spinal cord may be so divided that 
the animal has neither sensation nor power of voluntary motion below 
the point of section, although sufficient nerve-fibres retain their integ¬ 
rity to transmit vaso-motor impulses, so that galvanization of a sensi¬ 
tive nerve below the point of section produces immediate rise of the 
arterial pressure without eliciting any pain-cries from the animal. Dr. 
J. F. Williams (Arch. f. Exper. Path. u. Pharm ., xiii. 1) has also found, 
after reduction of blood-pressure to zero by chloral, that digitalis will 
cause rise of pressure. This does not, however, throw much light upon 
the vaso-motor action of the drug, because by enormous doses of chloral 
the heart is almost as much affected as is the vaso-motor system. Drs. 
Brunton and Meyer (Journ. Anat., p. 138) injected digitalin into the ear 
of a rabbit whose cervical sympathetic and pneumogastrics had been 
destroyed, but were unable to obtain any satisfactory result; there was 
certainly no constant perceptible contraction, although sometimes the 
vessels were seen to empty themselves more rapidly than before the 
injection. By consentaneous, independent researches, Drs. Ringer and 
Sainsbury (Medico- Chir. Trans., lxvii.) and Messrs. Donaldson and 
Stevens (Journ. Physiol., iv.), using the method of Gaskell more or less 
modified, have apparently proved that digitalis acts upon the walls of 
the arterioles. They destroyed the nerve-centres of a terrapin, excised 
the heart, and connected bottles in such a way with the blood-vessels 
that liquids would run through the arteries and come out through the 
veins. Under such circumstances they noted a marked reduction of 
the rate of flow when soluble digitalin was placed in the artificial 
serum. 

Professor R. A. Robert f (Therap. Gaz., vol. iii., 1887), in a series of 
experiments similar in principle to those of Ringer and Sainsbury, but 
made upon the excised kidney, found that digitalis retards greatly the 
flow of liquid through the organ, and therefore acts directly upon the 
coats of the smaller vessels. I think that it must be acknowledged 
that digitalis has a direct action upon the walls of the arterioles, but it 


* A similar rise has been observed by Kaufmann, who does not, however, give the extent 
of it ( loc. cit., p. 406). 

f Professor Robert tested two specimens of digitoxin and digitalein which had been sup¬ 
plied by Professor Schmiedeberg, their discoverer, and found that instead of contracting the 
vessels of the kidney they actively dilated them and increased the flow of liquid. 

23 



354 


GENERAL REMEDIES. 


is highly probable that it also acts upon the vaso-motor centre in the 
medulla. 

It has been shown that the dierotism in the frog’s pulse is due 
to an attempted diastole before the systolic impulse has yielded; and 
Kaufmann has determined that in the mammal a similar partial relax¬ 
ation, arrested by a renewed very brief systole, occurs and gives origin 
to a double pulse. Kaufmann has also noticed that a tendency to car¬ 
diac tetanus is manifested in the horse, as in the frog, under the influ¬ 
ence of digitalis, but that in the former animal a permanent, complete 
cardiac spasm never occurs. He has further experimentally determined 
that the diastolic as well as the systolic intra-ventricular pressure is 
increased, but that the diastolic intra-auricular pressure is slightly 
diminished. If it should be hereafter proved that these are constant 
phenomena, it would appear that the drug acts upon the ventricles 
rather than upon the auricles. 

The following proposition expresses our present knowledge, and 
probably is very close to the truth: 

Digitalis in moderate doses stimulates the muscular-motor portion of the 
heart (probably its contained ganglia), increases the activity of the inhibi¬ 
tory apparatus , and causes contraction of the arterioles , probably by an 
action on the vaso-motor centres in the cord, and also upon the walls 
of the arterioles. As a consequence of the first action, the cardiac 
beats become much stronger; as the result of the last, there is narrow¬ 
ing of the blood-paths, and to the passage of the vital fluid an increased 
resistance, which, acting on the already excited inhibitory system, aids 
in the slowing of the pulse. 

According to my own experience, decided therapeutic doses of digi¬ 
talis, in man as in other mammals, produce great reduction and some¬ 
times dicrotism of the pulse, and increase the size and force of the 
wave; at the same time the arterial tension is augmented. Poisonous 
doses induce, after a time, increase of the pulse-rate, with smallness 
and weakness of the wave and lowered arterial pressure. 

Sphygmographic studies of the effect of digitalis upon persons suf¬ 
fering from various acute and chronic diseases have been made by M. 
Legroux, M. Bordier {Bull. Therap ., 1868, p. 110), Constantine Paul 
{Bull. Therap ., 1868, p. 193), and Paul Lorrain {Journal de VAnat. et de 
la Physiol., 1870). The problems offered by these gentlemen are so 
complex as to render a detailed study almost impossible; but, as a 
whole, their tracings seem to confirm my personal experience. Paul 
Lorrain calls attention to the fact that when the drug has reduced the 
pulse-rate very greatly a second abortive systole can, on auscultation, 
sometimes be heard occurring during the long diastole, and some of his 
sphygmographic tracings are markedly dicrotic. It is evident that in 
man the second systolic movement occurs precisely as in animals; and 
it seems very certain that the proposition framed for the lower mam¬ 
mals applies also to man. 


CARDIAC STIMULANTS. 


355 


When the pulse has been reduced by digitalis to forty or fifty a 
minute, the change from the recumbent to the erect position will not 
infrequently suffice to alter at once its character, so that it will become 
feeble, small, and one hundred and fifty per minute. The explanation 
of this seems to be that the heart of such a patient is just in the posi¬ 
tion in which the diastolic impulse is being overcome by the excessive 
systolic stimulation of the drug. While the patient is recumbent, the 
line is not passed over, but the additional stimulation of the erect posi¬ 
tion carries the heart beyond the limit of regular diastole, and the over¬ 
effects of the drug are at once manifested. 

The influence of digitalis upon the urinary secretion in health has 
been studied by numerous observers, with such diverse results as to 
prove that the action of the drug on the kidneys is so inconsistent and 
varying as to render it probable that it is in great measure indirect 
rather than direct. Thus, Jorg, Hammond ( Proc. Biol. Dept. Acad. Nat. 
Sciences , Phila., Dec. 1858), and Brunton (loc. cit .) have found the secre¬ 
tion more or less decidedly increased, and Homolle (. Archives Generates, 
July, 1861), Winogradoff (Virchow's Archiv, Bd. xxii., 1861), Stadion, 
and, according to Brunton, also Krahmer, Kluyskens, Vassal, and Shohl, 
have found it either uninfluenced or diminished. Kaufmann has found 
it uniformly diminished in the dog (loc. cit., p. 411). 

The urea in the apparently very careful experiments of Winogra¬ 
doff (loc. cit.), of Stadion (Prager Vierteljahrs. f. Prakt. Heilk., 1862, Bd. 
lxxii.), and of Hammond (loc. cit.), was diminished, while in the almost 
equally elaborate experiments of Brunton (loc. cit.) it was increased. 
All four observers noted lessening of the chlorides. Megerand, using 
the crystallized digitalin of Nativelle, found his urine increased twenty- 
five per cent, but his urea diminished twenty per cent. Auguste Meus- 
nier has sought without success for sugar in the urine both of patients 
taking large doses of digitalis and of rabbits poisoned with the drug 
(Paris Thesis, 1868). Kaufmann (loc. cit., p. 413) states that digitalis 
leaves, or preparations which produce local irritation, cause in the dog 
an increase in the elimination of urea, but that when digitalin is given 
in solution, so as to avoid all local irritation, the excretion of urea is 
diminished. 

It is very certain that toxic doses of digitalis lower the temperature 
a number of degrees in healthy men and animals. It would seem, 
however, that the fall of temperature is generally, if not always, pre¬ 
ceded by a rise, as has been noted by Bouley and Reynal, by Dumeril, 
Demarquay, and Lecointe (quoted by Brunton), by Hirtz, by Legros 
(These, 1867, quoted by G-ourvat), and by Gourvat (Gaz. Med. de Paris, 
1871, p. 572). Kaufmann believes that such rise is due to the local 
irritation produced by the drug, and asserts that if no irritation be 
produced there is always in the animal a fall of rectal temperature 
(0.4-0.5° C.) after even a feeble dose of digitalin. 

The effect of therapeutic doses in the normal condition has not been 


356 


GENERAL REMEDIES. 


closely studied, that I am aware of. But in a number of cases, chiefly 
of pneumonia, Z. E. Coblentz (Strasbourg Thesis, 1862) found that 
about twelve hours after the fall of the pulse there was also a fall of 
temperature. The tendency of our present knowledge is to connect 
the changes in temperature induced by digitalis with the changes of 
the circulation; and it seems very possible that therapeutic doses in 
health may be found to increase bodily heat, although in fever they 
may diminish it. 

Therapeutics. —The chief clinical use of digitalis is in diseases of 
the heart; and from what has been said of its physiological action it 
logically follows that it should be useful in loss of cardiac power. 

When the muscle of the heart is for any reason unequal to the task 
set it, the systoles become rapid and imperfect, and by this irregular 
action the ventricles, neither completely filling nor completely emptying 
themselves, increase the embarrassment. XJnder these circumstances, 
digitalis, by lengthening the diastolic pauses and increasing the force 
of the systolic contractions, causes the ventricles to fill themselves com¬ 
pletely in the one and to empty themselves completely in the other 
act. By subduing irregular action through the inhibitory nerves, and 
by energizing the muscular power of the heart-walls, the remedy is of 
incalculable service, and, increasing arterial tension all over the body, 
causes the disappearance or lessening of symptoms due to low pressure 
in the arteries. 

It is a logical necessity, if our reasoning as to the physiological 
action of digitalis has led to a correct result, that the drug should be 
of the greatest service when the lesion is simply loss of cardiac power • 
and clinical experience tallies with this a priori argument. In simple 
dilatation , or in simple failure of the cardiac muscle without valvular 
lesion, the results of the use of digitalis are most favorable. 

On the other hand, in simple hypertrophy digitalis does harm, and 
should never be used. It must be borne in mind that although this 
agrees with what the experimentalist has proved to be the action of 
digitalis, yet it was discovered independently as a clinical fact by prac¬ 
titioners. Thus, Niemeyer, who ridiculed experimental therapeutics 
because he would not take the trouble to study them deeply and jirac- 
tically and was therefore incapable of understanding them,—Niemeyer 
says, “ Digitalis in pure uncomplicated hypertrophy is unsuitable.” 

Valvular lesion of the heart, as is well known, gives rise under un¬ 
favorable circumstances to dilatation, but in favorable cases to hyper¬ 
trophy, or rather in the great majority of cases to hypertrophy with 
dilatation. Following out the principles already inculcated, it might 
seem at first that the use of digitalis in hypertrophied hearts with 
valvular lesion ought to be reprobated. But it is known clinically that 
digitalis often does good in valvular lesion with enlargement of the heart. 
The results of logical deductions from our physiological conclusions as 
premises are, however, not really at variance with this. It must be 


CARDIAC STIMULANTS. 


357 


borne in mind that structural hypertrophy and functional hypertrophy 
are different things: by this is meant that although a heart be enlarged 
and absolutely stronger than normal, yet it may be, relatively to the 
work required of it, weak. Thus, if 1 represents the normal work of 
the heart and 1 its normal power, if the former be increased to 4 and 
the latter to 3 the heart is really in the position of a weak organ, 
although possessed of three times its original strength. Hence it is 
that digitalis is often useful in valvular disease with hypertrophy. In 
the vast majority of cases the heart with diseased valves is in the posi¬ 
tion just spoken of; but sometimes the work advances only to 2 and 
the strength to 3; then the hypertrophy becomes excessive, and digi¬ 
talis will increase the difficulty. In almost all cases the increased power 
of hypertrophy, unless the muscle be degenerated, renders effectual 
smaller doses than can be used in dilatation, and also increases the 
danger of the over-action of large doses. 

In mitral insufficiency and in mitral stenosis digitalis is often of great 
service. It is evident that in both instances the valvular lesion leads 
as its first result to pulmonic hyperasmia. How does the digitalis lessen 
this? In the case of stenosis, the diastole being lengthened by the 
remedy, the auricle is afforded more time to empty itself into the ven¬ 
tricle through the narrowed orifice, and at the same time is strengthened 
in its contracting power; evidently, then, the left ventricle when its 
systole occurs will have much more to contract on than before the 
digitalis was administered, and the amount of blood in the systemic 
circulation will be increased,— i.e., the amount in the pulmonic circula¬ 
tion will be diminished; further, the right ventricle will have greater 
power afforded it to force the blood through the lungs,— i.e., to resist 
the recoil from the left auricle to which the impeded valve gives 
origin. 

In mitral insufficiency the mechanism is different, but the result is 
the same. The increased power of the systole will throw proportion¬ 
ately more blood through the aortic orifice than through the partially 
open valve. The opening at the insufficient mitral valve is much 
smaller and more obstructed than the aortic orifice. As the force or 
rapidity of the current increases under the action of digitalis, the 
friction becomes greater at both orifices, but the ratio of increase is 
evidently far higher in the small choked mitral leak than in the wide 
aortic opening. Hence the large orifice constantly gains upon the 
smaller as the cardiac force is increased, and, more blood passing into 
the systemic circulation, the pulmonic vessels are relieved. Again, the 
right ventricle shares the stimulant action of the drug, and acts more 
strongly upon the pulmonic circulation, resisting the direct backwai’d 
flow from the auricle. There are cases of mitral cai’diac disease in 
which digitalis seems to be indicated, but when given acts unhappily. 
In some of these cases the augmented disti'ess is px*obably caused by a 
strain upon the auricles. If the venti’icle be already too strong for the 


358 


GENERAL REMEDIES. 


auricle, and if by virtue of a very patulous mitral valve the backing 
of the blood upon the auricle is very easy, it is readily understood how 
increasing the power of the ventricle may augment the auricular strain. 
Especially is this consideration important in the light of Kaufmann’s 
researches, which seem to show that the ventricle is more affected by 
digitalis than is the auricle, and hence that a stimulated ventricle may 
have to be met by a non-stimulated auricle. 

In aortic constriction digitalis is useful when the heart-power begins 
to fail. In these cases compensatory hypertrophy, with slowness of 
action, is very apt to occur, or even to become excessive: much more 
frequently does this happen than in mitral disease. Again, in aortic 
insufficiency the prolonged diastole of digitalis action favors the return 
of blood to the heart, and is not advantageous. It is evident that 
digitalis is not so generally useful in aortic as in mitral disease: never¬ 
theless, when the heart-muscle fails, and the hypertrophy is not com¬ 
pensatory, the drug is useful in both aortic stenosis and insufficiency.* 

From the considerations which have been brought forward, it is 
very evident that a knowledge of the relation of the heart-muscle to 
the work required of it in any individual case is much more necessary 
to the therapeutist than to know what valve is diseased. 

In “ irritable heart ” of soldiers, a disease or condition of cardiac 
irritability evidently connected with muscular weakness, and very 
probably dependent upon exhaustion of the inhibitory nerves, Dr. Da 
Costa {American Journal of the Medical Sciences , Jan. 1871) found that 
in the early stages of the affection digitalis not only acted better than 
any other remedy, but even, when administered continuously for some 
time, often effected a permanent cure. When hypertrophy had taken 
place, the drug was of little use. 

The relief afforded by digitalis in not too inveterate cardiac disease 
is often in a measure permanent, because the drug may aid very mate¬ 
rially in the production of compensatory hypertrophy. Dilatation is 
certainly more apt to occur when the muscular fibre is lax and acting 
feebly than when it is toned up and in vigorous play; secondly, the 
stimulus to action in a muscle is almost of necessity directly or indi¬ 
rectly a stimulus to its nutrition ; lastly, and most important, improved 
systemic circulation means in a far more intense degree improved blood- 
supply to the cardiac muscle, as is shown by the following considera¬ 
tions. 

During systole the cardiac muscle contracts so as to squeeze out 
completely all the venous blood from the heart-walls. The arterial 
blood enters during diastole, and the force which drives it into the 
relaxed walls is derived from the arterial system. The coronary arteries 
arise nearly at a right angle to the aorta: the blood squirts into the 
latter during systole in an unbroken stream, and probably does not enter 


* Consult Fothergill, Antagonisms of Medicines, Phila., 1878, p. 85. 



CARDIAC STIMULANTS. 


359 


freely the coronary artery. But when the reflux wave comes, the aortic 
valve flaps to, and the whole pressure of the blood-column forces the 
liquid into the open cardiac arteries. If the arterial system be emptied, 
or nearly so, the arteries are not distended sufficiently to give origin to 
a powerful reflux wave, and but little blood enters the coronary artery, 
i.e., the cardiac walls. The dilated feeble heart is unable during systole 
to free its walls thoroughly of venous blood, and during diastole the force 
is lacking for driving in the arterial blood. Digitalis enables the cardiac 
muscle to free itself thoroughly of venous blood, and at the same time, 
by restoring to a greater or less degree the normal balance of the circu¬ 
lation and removing the excess of blood from the general venous system, 
gives the aorta sufficient blood to provoke an active reflux.* 

If in aneurism , or in general capillary atheroma , there be increased 
resistance to the circulation, and the heart have not sufficient power to 
meet this, digitalis may be useful, but must be employed with caution. 
It undoubtedly increases arterial pressure; and this increased pressure 
may prematurely rupture an atheromatous cerebral capillary or tear 
open the thinned wall of an aortic aneurism. The use of digitalis for 
the purpose of “ quieting the circulation” in aneurism is very dangerous. 
I have seen immediately fatal hemorrhage produced thereby. 

In cardiac dropsy digitalis is of service probably not only by regu¬ 
lating through the heart the circulation, and by evacuating the surplus 
fluid through the kidneys, but also by an action upon the vessels. 
Clinicians do not allow enough for the role of the vaso-motor nerves in 
dropsy. Without saying more as to the clinical side of this question, 
which I have discussed elsewhere ( American Journal of the Medical 
Sciences , July, 1871), it may be allowable to allude to the experiments 
of Banvier ( Comptes-Pendus , 1869, p. 1327), who found that when the 
vena cava was tied in a dog, and the sciatic nerve of one side cut, 
oedema occurred only in the leg whose nerve was divided. 

Digitalis in large doses is a very valuable cardiac stimulant in 
syncope or sudden collapse from hemorrhage or other cause. (See Pa¬ 
cific Med. and Surg. Journ., 1874, p. 273.) To overcome its slowness of 
action I have used it hypodermically often with the most remarkable 
effects. From twenty to thirty minims of the tincture should be in¬ 
jected into the arm, and repeated in half an hour if absolutely neces¬ 
sary, or one-fiftieth of a grain of the digitalin may be substituted. In 


* I have let this paragraph stand as in previous editions, although the experiments of 
Professor Martin seem to show that the circulation is most active in the heart’s wall during 
systole. The appearance of the wall of a diastolic heart as contrasted with that of a systolic 
heart makes one, however, loath to admit the conclusion that the blood enters the muscles as 
freely during systole as in the first period of diastole. Moreover, even if Professor Martin’s 
view were adopted, the therapeutic reasoning would only have to be changed in wording, not in 
drift; the facts remaining that the heart-muscle feels most powerfully failure of arterial cir¬ 
culation, and that therefore cardiac overwork and starvation are apt to go hand in hand, so 
that the relief of the circulation by the digitalis may bring about permanent nutritive changes 
in the heart-muscle. 



360 


GENERAL REMEDIES. 


my experience* the digitalin has several times given rise to severe local 
irritation, the tincture very rarely. 

A number of eminent physicians assert that they have obtained 
excellent results by the use of half an ounce of the tincture of digitalis 
in the treatment of delirium tremens , especially in those cases in which 
the pulse is very soft and feeble. The evidence of the value and safety 
of the remedy in such cases is too strong to be overlooked, but does not 
to my mind indicate the possession of narcotic properties by the drug. 
The rest and sleep which have followed the administration have proba¬ 
bly been the result of the cardiac stimulation and the increased flow of 
blood to the nerve-centres. Enormous doses of digitalis are tolerated 
in these cases, probably because the heart has become by long habit 
very much benumbed to the influence of stimulants. Their use is not, 
however, entirely free from danger. 

Closely allied to the last use of digitalis is its employment in poison¬ 
ing by substances such as muscarine , delphinine , and aconitine , which 
arrest the heart in diastole. Boehm has shown ( Pfluger's Archiv , Feb. 
1872) that in digitalis-poisoning of the frog, even when systolic cardiac 
arrest has occurred, these substances will often restore the cardiac 
movements,—a proof that real antagonism exists in their action ; and 
Dobie reports a case {Brit. Med. Journ ., Dec. 1872) of recovery after 
the ingestion of an ounce of Fleming’s tincture of aconite, apparently 
due to the hypodermic injection of twenty minims of tincture of digi¬ 
talis and the exhibition by the mouth of three doses in an hour of a 
mixture of tincture of digitalis (one drachm each dose), brandy, and 
ammonia. 

Digitalis is often of great value in various acute diseases,j" such as 
adynamic pneumonia and adynamic fevers , by maintaining the heart’s 
action. It can have no effect upon the diseases themselves, but may 
help most opportunely to sustain the heart during a crisis or a period 
of strain upon it. When in any form of pneumonia the right heart is 
yielding to the strain of forcing blood through pulmonic capillaries 
pressed upon and reduced in their aggregate lumen by exudation, digi¬ 
talis may be of the utmost service. 

With the idea that digitalis is an active antipyretic , it has been pre¬ 
scribed in various acute diseases, sometimes with asserted good results. 
As already stated, toxic doses of digitalis at first elevate the tempera¬ 
ture ; and proof is wanting that in healthy men therapeutic doses have 
any decided influence in depressing the temperature. There is, there¬ 
fore, no good physiological basis for the antipyretic use of digitalis; at 
the same time, it is very possible that it may directly or indirectly 


* Local irritation, and even the production of abscesses, have also been noted by various 
observers besides myself. See Witkowski, Deutsches Archiv f. Klin. Mecl., xviii. 142 ; also 
Pel, Centralbl. f. Med. Wiss., 1877, p. 169. 

f Consult Hankel, British and Foreign Medico-Chirurgical Reviexc, xxxi. 513; Grimshaw, 
Dublin Quarterly, June, 1873; Anstie, London Practitioner, Sept. 1873. 



CARDIAC STIMULANTS. 


361 


lower the temperature in disease. Clinical proof of this is, however, 
still wanting. The strongest evidence in favor of such action is fur¬ 
nished by the records of Professor Wunderlich ( Medical Thermometry , 
Syd. Soc. Trans., p. 325), according to which from half a drachm to a 
drachm of digitalis, given in divided dose during three or four days in 
the second or third week of severe typhoid fever , immediately produces 
a slight fall of temperature in a large proportion of the cases, and 
somotimes a considerable fall. This fall is said not to last more than a 
day, when the temperature rises again, but in cases favorably affected 
does not regain the original height; the pulse is very much lowered in 
frequency, and remains about uniform for four days. It is evident 
that at least in some of these cases of Wunderlich’s the drug was given 
about the time natural defervescence would be expected to occur, and 
that the slight reduction of temperature brought about at such time 
does not argue very strongly in favor of the proposition that digitalis 
is a powerful antipyretic in disease. Far more extensive and complete 
observations must be made upon a rising, not a falling, temperature, 
before any satisfactory conclusion can be reached. At present the 
antipyretic use of digitalis should be purely tentative. In puerperal 
fever , Winkel ( Phila. Med. Times, 1874, iv.) believes digitalis does good 
by its action on the circulation, by contracting the arterioles of the 
uterus and by lowering temperature. 

The property of causing contraction of all unstriped muscular fibres 
has been attributed to digitalis, but, while the probabilities are certainly 
such as to invite investigation, we have no definite knowledge upon 
the subject. Mr. Dickenson ( Med.-Chir. Trans., vol. xxix.) asserts that 
it has a powerful action in causing the uterus to contract and to arrest 
hemorrhage,—a few minutes after an ounce and a half of the infusion 
is swallowed in menorrhagia, severe pains resembling those of the first 
stage of labor coming on, with a momentary profuse discharge of blood 
and clots, if there be any present, followed by arrest of the flow for 
hours. Stadion {Syd. Soc. Year-Book, 1862, p. 451) states that digitalis 
is capable of temporarily but completely annulling the activity of the 
sexual organs, and that it may be regarded as a true anaphrodisiac. 
M. Gaunot {Phila. Med. Times, iv. 30) makes the same assertion, and 
advises the use of the drug in spermatorrhoea. 

The use of digitalis as a diuretic will be considered under that 
heading. 

Toxicology.— In poisoning by digitalis, the first symptom of any 
severity is generally vomiting of mucus and bile, very violent and very 
often repeated. At the same time a feeling of heat of the head, dis¬ 
ordered vision, and vertigo manifest themselves. The pulse at this time 
in the horizontal position may be full and strong and slow, but on the 
patient’s rising becomes weak and rapid. The face is pale. The vomit¬ 
ing continuing, profound prostration comes on, the pulse becomes feeble, 
small, irregular, although the beat of the heart may be sti’ong and hard. 


362 


GENERAL REMEDIES. 


The eyes are very prominent, the pupils fixed and dilated: according to 
Tardieu, an almost diagnostic symptom is the blue color of the sclerotic. 
Abundant salivation sometimes occurs. Intense headache and pains in 
the back or limbs are often complained of. Diarrhoea is very generally 
present; the urine may be suppressed. The intelligence is often perfect 
in the midst of profound collapse, but delirium more or less violent 
finally comes on. Death, usually preceded by stupor or by convulsions, 
takes place most frequently in one or two days, but has occurred as late 
as the tenth day, and as early as three-quarters of an hour.* 

In the majority of cases of digitalis-poisoning the patient recovers. 
When this happens, the symptoms gradually ameliorate. Cardiac 
weakness, and even a bruit de souffle , with more or less exophthalmos, 
is said to have persisted for weeks in some cases. In poisoning by 
digitalin the symptoms are those of rapid digitalis-poisoning,—violent 
vomiting, intense cephalalgia, and sometimes rachialgia, irregular, feeble, 
intermittent pulse, and paroxysms of suffocation. 

The minimum fatal dose of digitalis is not known. A large tea¬ 
spoonful of the tincture is said to have caused alarming symptoms in a 
young puerperal woman (Tardieu, Clinique , p. 685, Obs. VIII., Paris, 
1867); twenty grains of the extract proved fatal on the tenth day 
{Ibid., Obs. VI.), and two and a half grammes of the leaves in infusion 
on the fifth day {Ibid., Obs. X.); fifty granules (gr. one-fiftieth each ?) 
of digitalin have been recovered from {Ibid., Obs. XII., XIV.); about 
one-fourth of a grain of digitalin {Gazette Hebdom., July, 1874) pro¬ 
duced very violent but not lethal symptoms. In the only fatal case 
of digitalin-poisoning I know of {Affaire Couty de la Pomerrais), the 
amount ingested was unknown. 

The treatment, after the evacuation of the stomach and bowels, and 
the very free administration of tannic acid, as the best, although an unre¬ 
liable, chemical antidote, should consist in the exhibition of opium and 
of alcoholic stimulants, with rest in the horizontal position. I know of 
no recorded experiences with the antagonistic poisons to digitalis, such 
as aconite or muscarine. As it is possible that while so far as the heart 
is concerned they may be really antagonistic and yet may intensify the 
action of digitalis on the cord, their use requires caution. 

Two cases, one ending fatally, of what may be considered chronic 
digitalis-poisoning, have been reported by Dr. Kohnhorn ( Lancet , 1876, 
i. 583). The symptoms were loss of appetite, tinnitus aurium, vertigo, 
lowering of the rate and force of the pulse, diarrhoea, weakness, general 
anaemia, and syncopal attacks. The only lesion found at the autopsy was 
congestion with ecchymosis of the gastro-intestinal mucous membrane. 


* See case reported by M. Barth, quoted by Tardieu. In a case of poisoning by ten 
grammes of tincture of digitalis, said to contain twenty milligrammes of digitalin, the symp¬ 
toms were vomiting, great pain in the head, prostration, a very small pulse,—forty per minute, 
—anuria, and a systolic bruit heard over the whole heart, having its maximum intensity at 
the base. Recovery occurred in two days (Mem. Soc. de MSd. de Bordeaux, 1884, 397). 



CARDIAC STIMULANTS. 


363 


Administration. —Digitalis may be given in substance in the form 
of pills; the dose being one grain three times a day, and increased until 
some effect is produced. The solid extract (Extractum Digitalis , XJ.S.) 
is less reliable than the leaves; its dose is one-fourth of a grain. When 
a rapid action is desired, one of the following officinal preparations, or 
the digitalin, should be used: Infusum Digitalis (1 to 66.6),—dose, one 
fluidrachm to half a fluidounee; Tinctura Digitalis (1 to 6.66),—dose, 
five to twenty drops; Extractum Digitalis Fluidum, —dose, one to two 
drops. Abstractum Digitalis, XJ.S.— Abstract of digitalis is a good prepa¬ 
ration, twice as strong as digitalis itself, and to be given in half the 
dose.* 

In emergencies where single doses are administered they may be 
very much larger than those here given. Thus, of the tincture two 
fluidrachms or even half an ounce may be exhibited; of the infusion, 
a wineglassful. Moreover, in desperate cases, the physician is justified 
in taking the risk of the administration of repeated very large doses 
of digitalis. I have seen a number of cases of excessively severe 
chronic cardiac failure, with Cheyne-Stokes respiration, orthopnoea, and 
almost absolute insomnia, in which the administration of half a drachm 
or a drachm of the tincture of digitalis three or four times a day has 
enabled the patient to resume for a time the ordinary duties of life. 
In almost every case of this character which I have watched, death 
has finally come by sudden syncope, while the patient was still going 
about and enjoying a comfortable life. I do not believe that the arrest 
of the cardiac action has been due to a direct action of the drug, but 
simply that the enormous doses of digitalis have stimulated the heart 
and steadied its expenditure of force, so that it was enabled to go on 
until the last particle of cardiac vital power was exhausted. I may 
further say that in the experience of twenty-five years in which I have 
used digitalis, frequently in enormous doses, I have never seen a case 
in which I thought it did serious harm by a toxic action. The infusion 
of digitalis is believed by many practitioners to be more active than 
the tincture. This is simply because the infusion is commonly used in 
much larger doses than the tincture. Either preparation is efficient if 
properly made from fresh leaves. 

When digitalis is administered persistently, its first evident influence 
may be suddenly developed after long delay (case, Phila. Med. Times , 
vol. ii. p. 24). It is said that sometimes the first marked symptom of 
this so-called cumulative action is severe syncope, followed by paraplegia, 
vomiting, diarrhoea, delirium, general insensibility, and death. Such 
cases must be extremely rare: usually a sudden drop of the pulse is the 
most serious effect, provided that the administration of the remedy be at 
once suspended. It is a matter of much importance to determine when 


* According to Fraenkel’s experiments, the most certain preparation of digitalis is the 
vinegar; then comes the infusion, and finally the tincture ( Charite-Annalen , 1881, 225). 



364 


GENERAL REMEDIES. 


this cumulative action is to be expected. It is probably connected with 
slow absorption and elimination, and is much more prone to occur when 
there is no diuretic effect. It is also very apt to appear after tapping: 
the sudden removal of pressure from the vessels leads to the picking 
up from the tissues of serum,—saturated, it may be, with digitalis 
principles,—and also to the rapid absorption of any digitalis which may 
be in the alimentary canal. Drs. T. Lauder Brunton and J. Theodore 
Cash ( Lond. Practitioner , xxxiii. 272) find that high temperature so 
weakens the cardiac inhibitory apparatus in the cat that it will not 
respond to digitalis, and believe that this direct action of the bodily 
heat is in many cases of fever the reason why digitalis will not act. 
They caution against its too bold use in diseases with a sudden defer¬ 
vescence, because when the temperature suddenly falls, inordinate digi¬ 
talis effects may appear. It should be a general practice in the persist¬ 
ent administration of digitalis to interrupt its use occasionally so as to 
allow a clearance of the system. 

As already stated, the digitalin of commerce is a complex body of 
various composition, power, and even properties, and there is no suffi¬ 
cient reason for its employment. Even for hypodermic use the tincture 
seems preferable, as the digitalin solution appears to undergo change in 
a few hours, and usually causes more irritation when injected than does 
the tincture. The dose of digitalin is one-fiftieth of a grain. 

CAPFEA—COFFEE. 

The seeds of the Caffea Arabica are such familiar objects that space 
will not be here occupied with their description. It should be remem¬ 
bered that roasted coffee contains, besides Caffeine , an empyreumatic 
oil, which has decided effects upon the system. 

CAFFEINA—CAFFEINE. U.S. 

Caffeine occurs in long, snow-white, silky, opaque, odorless crystals, 
sometimes conjoined into feathery crystals, of a feeble bitter taste. It 
has a neutral reaction, but unites with acids to form salts. It is soluble 
in 100 parts of water, in 160 parts of absolute alcohol, and in 220 parts 
of ether. It was first discovered in coffee by Bunge ( Schweigg. Journ. 
Chem. Phys., xxxi.), in 1820. In 1827, Oudry discovered a principle in 
tea which he called theine, which in 1838 was proved by Mulder and C. 
Jobst to be identical with caffeine. Martius, Stenhouse, J. Attfield, and 
other chemists have also shown that caffeine is the active principle of 
Guarana (the fruit and leaves of the Paullinia sorbilis of Brazil), of 
Mate, or Paraguay tea (the leaves of the Ilex Paraguaiensis),* and of 


* Mate is used in South America very largely as a substitute for tea. According to the 
analyses of Dr. Peckolt, of Rio Janeiro, it contains 2.5 parts in a thousand of calfeine; but M. 
Byanon found 1.85 per cent, of the alkaloid (Bull. Thirap., xciii.). It is sold in two forms: 
mate in leaf is prepared as ordinary tea is, and taken with sugar and milk to taste ; mate in 
powder is prepared by pouring upon the powdered mate boiling water, and the infusion is 



CARDIAC STIMULANTS. 


365 


the Kola nut of Africa (Cola acuminata). H. M. Smith (Journal of Ap¬ 
plied Science, Sept. 1874) has also found it in Yaupon (the leaves of our 
native Ilex Cassine). 

Physiological Action.— The study of the physiological action of 
caffeine in relation to its therapeutic use can be most conveniently made 
in two divisions, namely, the action of toxic and that of minute doses. 

Toxic Doses. —The influence of the alkaloid upon frogs has been 
studied by Albers ( Deutsche Klinik , 1853, p. 370), Falck and Stuhl- 
mann ( Virchow's Archiv, Bd. xii. p. 365), Mitscherlich ( Der Cacao und 
die Chocolade, Berlin, 1859), I. Hoppe (A’ Echo Med., 1858), Brill ( Das 
Kaffein, Inaug. Diss., Marburg, 1861), Oscar Johannsen ( Ueber die 
Wirkung des Kaffeins, Inaug. Diss., Dorpat, 1869), and various other 
observers. The minimum fatal dose is stated by Leven (Arch, de 
Physiol., 1858) to be .015 grain in a frog of moderate size. According 
to the various observers, the chief symptoms induced by poisonous 
doses in the batrachian are muscular quietness and weakness, with dis¬ 
turbance of respiration, succeeded by a stage of violent tetanic con¬ 
vulsions, ending in general paralysis and death by asphyxia, the heart 
beating after the cessation of respiration, although evidently much 
affected. 

Johannsen denies that there are any true convulsions produced in 
the frog by caffeine, but merely a rigidity, muscular in its origin and 
very closely allied to that produced by heating a muscle,— i.e., to post¬ 
mortem rigidity. Pratt, however, previous to the publication of the 
paper of Johannsen, had very clearly recognized the existence both of 
this muscular stiffness and of convulsions, and had pointed out the 


sucked up through a tube, the bulbous end of which is furnished with a fine sieve, or the 
powder is thrown into boiling water, and when the mixture recommences boiling, cold water 
is poured into it; this precipitates the powder, and the infusion is taken clear. 

Chemically the alkaloid obtained from tea and known as theine is identical with caffeine; 
indeed, most of the caffeine of commerce (Dr. Charles Rice, American Druggist, March, 1886) is 
obtained from the tea leaf. If, however, the experiments of Dr. Thomas J. Mays are confirmed, 
theine is not physiologically identical with caffeine. The argument that tea and coffee differ 
in their gross effects on the human body, and that therefore the alkaloids cannot be identical, 
has no force, because coffee contains an empyreumatic oil which is made during the process of 
roasting, and is not found in tea. Dr. Mays asserts as the result of his experiments, made 
chiefly upon frogs, that theine differs from caffeine as follows : 1. Theine principally influences 
sensation, while caffeine does not. 2. Theine produces spontaneous spasms and convulsions, 
while caffeine does not. 3. Theine impairs the nasal reflex early in the poisoning process, 
while caffeine does not, if at all, until in the very last stage. 4. The lethal dose of theine is 
larger than that of caffeine. Dr. Mays also claims that theine is a powerful local anaesthetic, 
while caffeine is not. The comparison of the various papers of Dr. Mays ( Trans. Coll, of 
Physicians, Phila., 1866, viii. 365; Journ. of Physiology, vii. 458; Therap. Gaz., 1885, 1886) 
does not seem to me to confirm all these alleged differences, and the matter must still be con¬ 
sidered as sub judice. The clinical results obtained by Dr. Mays are sufficient to warrant the 
trial of theine citrate injected in a dose of a third to a half of a grain over painful nerves 
or inflamed parts as a local anaesthetic. 

Guaranine is also thought by Dr. Mays to be distinct in its physiological action from 
caffeine. Indeed, it seems to stand half-way between theine and caffeine in its influence. It 
does not seem certain that the alkaloids which were used by Dr. Mays were pure and genuine. 



366 


GENERAL REMEDIES. 


differences between the latter and those of strychnine, differences which 
are the result of the peculiar condition of the muscles in caffeine-poison¬ 
ing. He says, “ At the commencement there is the usual rapid action 
and abrupt contraction of the muscles; but as the phenomena go on, 
the muscles seem to act sluggishly, requiring quite an interval to con¬ 
tract and relax, . . . the spinal cord having to deal with muscles al¬ 
ready much contracted by the local action of the poison on their fibres.” 
Moreover, Leven (loc. cit., p. 182) destroyed entirely the lower third of 
the spinal cord in a frog, and administered caffeine, when the charac¬ 
teristic convulsions appeared in the upper two thirds of the animal, but 
not in the lower third. 

Pratt included all the tissues of a frog, except the spine, in a tight 
ligature just above the bifurcation of the aorta, and administered caffeine, 
when the anterior legs became very stiff, and had also occasional severe 
convulsions, in which the hind legs participated, although between the 
paroxysms they were perfectly relaxed. He also noted in a number of 
experiments that the hind legs became very rigid, but not convulsed, 
after the lower portion of the spinal cord had been removed and the 
animal poisoned. 

Buchheim and Eisenmenger (quoted by Schmiedeberg) have recently 
corroborated the muscular changes noted by Johannsen, but insist, with 
Pratt, that there are also true nervous convulsions. O. Schmiedeberg 
(.Archiv fur JExper. Pathol, und Pharm ., Bd. ii.) believes that he has 
reconciled these differences of observations by finding that the alkaloid 
acts much more powerfully upon the muscles of Eana temporaria than 
upon those of Rana esculenta; so that a dose of caffeine which causes 
intense general muscular stiffness in the former produces in the latter 
only true convulsions, the convulsions in R. temporaria being prevented 
or masked by the disorder of the muscles. 

The most recent researches (E. Leblond, La Caffeine , Paris, 1883; 
W. Filehne, Arch. f. Anat. und Physiol ., 1886) do not confirm this idea 
of Schmiedeberg, but show that the differences depend rather upon the 
size of the dose and variations in the sensitiveness of individual frogs. 
Johannsen pointed out that the rigidity spreads from muscle to muscle 
as the hypodermically injected poison diffuses itself, and is never de¬ 
veloped in a leg to which access of the poison is denied; while Yoit 
found that muscular rigidity came on as usual after severing the nerve 
of a leg. The rigidity and paralysis are muscular, and the elaborate 
studies of Leblond appear to prove that there are at least two stages 
(similar to the phenomena of veratrine-poisoning) in the action of caf¬ 
feine upon the frog muscle, one in which the muscular excitability is 
exaggerated, and in which there is a tendency to prolonged tetanic con¬ 
tractions after even momentary stimulations of muscle, and the final 
stage of rigidity and lost excitability. 

The action of caffeine upon the muscle is readily demonstrated by 
throwing the isolated gastrocnemius of the frog into a one-per-cent, or 


CARDIAC STIMULANTS. ■ 


367 


even a weaker solution; in from two to three minutes the muscle 
becomes contracted, swollen, round, stiff, and unable to respond to the 
galvanic current. That it is the muscle-fibre that is affected is shown 
by the experiments of Pratt and Voit, already quoted, in conjunction 
with one in which Pratt found that when an isolated muscle was soaked 
in a solution of curare until the nerves were killed, and then thrown 
into a solution of caffeine, the usual rigidity was developed. Johannsen 
(loc. cit ., p. 22) states that when a muscle under the microscope is 
touched with caffeine, its fibres can be seen to contract half their 
length; and Paschkis and Pal, in a series of elaborate experiments 
([Med. Jahrbucher , 1886), found that caffeine, theobromine, and xanthine 
first augment and then destroy the contractility of the frog’s muscle 
with which they are brought in contact. Caffeine (trimethylxanthine) 
was the strongest; theobromine (dimethylxanthine) the next in power; 
xanthine the weakest. 

In birds poisoned with caffeine, the symptoms (Brill, loc. cit., p. 66) 
are irregular movements, apparently to some extent due to cerebral 
disturbance, increased rapidity and irregularity of respiration, spas¬ 
modic tremblings, and tetanic and clonic convulsions, with paralytic 
phenomena. In mammals the results of the toxaemia, as noted by 
various observers,*' are restlessness, hurried respiration, at first a slight 
lowering and afterwards a decided elevation of temperature f (Alex. 
Bennett), muscular weakness, tetanic and clonic convulsions, increasing 
general paresis, and finally death, apparently from paralytic arrest of 
respiration. There is still a good deal of uncertainty as to the nature 
of the convulsions; but Arnory in some not very conclusive experi¬ 
ments found that they did not occur below the point at which he had 
divided the cord. If this result be correct, the convulsions must be 
cerebral; but confirmation is lacking. Uspensky ( Reichert's Archiv, 
1868, p. 526) has found that forced artificial respiration in great meas¬ 
ure suspends the convulsions.J 

Nervous System .—There is no evidence that caffeine exerts a very 
marked influence upon the cerebrum of the frog, or even of some of the 
lower mammals, unless the convulsions induced by it are believed to be 
the result of some such action. In certain of the higher animals, such 
as the cat, it often produces a condition of almost frantic cerebral ex- 


* Leven ( Archives de Physiologic, 1868; Amory ( Boston Medical and Surgical Journal, 
i., 1868); Pratt (Ibid., ii. 1868); Alex. Bennett ( Edinburgh Medical Journal, Oct. 1873). 

f Attention has recently been called, especially by Professor Binz, to the effects of caffeine 
upon animal temperature. He states that minute doses have no effect upon the bodily tem¬ 
perature ; doses just enough to produce slight toxic symptoms cause a rise of 0.6° C.; exces¬ 
sive doses cause an elevation of 1° to 1.5° C., the maximum being reached in one to two hours; 
doses which rapidly kill have very little effect upon the temperature (Arch. f. Exper. Path. u. 
Pharm., ix. 31). 

J In an elaborate series of experiments, Dr. Bennett (British Medical Journal, 1874) 
found that the minimum fatal dose of the poison for the cat and the rabbit was a little over a 
grain for the pound, five and a half grains being required for a five-pound animal. 



368 


GENERAL REMEDIES. 


citement. The convulsions produced in the frog by eatfeine seem, how¬ 
ever, to be spinal. Both Pratt and Leblond have found that section 
of the cord high up does not prevent them, so that they are not cere¬ 
bral; while in Pratt’s experiments, as well as in those of Leven, 
destruction of the spine prevented their development. The conclusion 
seems established that in the frog caffeine acts as a motor spinal stimu¬ 
lant and also as a muscle-poison. 

Alex. Bennett has brought forward the theory ( loc. cit., and British 
Medical Journal , 1874) that caffeine paralyzes the posterior columns 
of the cord without affecting the anterior columns; but his evidence 
appears to me insufficient to prove his conclusions. He grounds his 
belief chiefly on finding that in poisoned frogs and rabbits galvaniza¬ 
tion of the posterior columns of the exposed cord produced either no 
muscular contractions or only such as were very much more feeble than 
those provoked by galvanization of the anterior columns. According 
to the general belief of physiologists, the anterior columns do not re¬ 
spond at all to stimuli: so that it is probable that the responses obtained 
by Bennett were due to irritation of the nerve-roots. 

The motor nerves appear not to be affected , since Alex. Bennett has 
found that after death from theine they retain their normal suscepti¬ 
bility, and Pratt surrounded one crural nerve of a frog with a paste 
“ of theine and water,” and irritated the spinal cord, when both legs 
responded with uniform alacrity. Bennett also tied the crural artery 
of a frog, poisoned it with the alkaloid, and found that irritation of 
the cord produced equally active contractions in the two legs. Upon 
the sensory nerves it is affirmed that the poison acts more decidedly. 
The chief evidence is furnished by Pratt, who found that when the left 
sciatic nerve of a frog was surrounded by a paste of theine and water, 
after ten minutes irritation of the right foot produced reflex move¬ 
ments, while irritation of the left foot failed to elicit any response. 
Leblond has noted marked hypercesthesia in the frog, and Rumpf 
affirms ( Schmidt's Jahrb ., Bd. cci. p. 123) that increased sensibility of 
the skin can be demonstrated in man. 

Circulation. —Caffeine has a direct influence upon the heart, although 
that viscus continues to beat in animals poisoned by the drug after the 
cessation of respiration. According to Yoit (quoted by Brill), in the 
frog the rapidity of the cardiac pulsation is at first increased, but the 
pulsations become slower and slower, and are accompanied by irregu¬ 
larity of rhythm, the heart finally ceasing to act, but still responding 
to stimuli at a time when the voluntary muscles are absolutely dead. 
Falk, Steehlmann, and Johannsen observed that caffeine first increases 
and then lessens the frequency of the cardiac pulsations in the frog. 
According to Johannsen, the lessening of the frequency comes on the 
more quickly and the more powerfully as the size of the dose is in¬ 
creased. After a time the heart begins to beat irregularly, with short 
intermissions, which, as time goes on, grow longer and longer, till at 


CARDIAC STIMULANTS. 


369 


last movement ceases. Johannsen found that the action upon the cut¬ 
out frog’s heart was the same upon the viscus in situ ; Leblond confirms 
this, and states that the heart is finally arrested in systole; so also 
does Dr. Thos. J. Mays ( Therap. Gaz., 1885, i. 84). 

Aubert and Haase ( 'Pfluger's Archiv, v. 608) find that the action 
of the alkaloid upon the pulsations of the frog’s heart varies greatly; 
and indeed the individual experiments of the authors previously quoted 
show such variation. This is confirmed by the research of Dr. Rios- 
chiro Maki ( TJeber den Einfluss des Camphers , Caffeins und Alkohols auf 
das JETerz, Strassburg, 1884). This investigator experimented upon the 
cut-out frog’s heart with the Williams apparatus, and found that the 
pulse was variously affected. In most of his experiments the arterial 
pressure— i.e., the heart’s work—was markedly lessened, but in a few 
cases it was distinctly increased. In the former edition of this work 
it was said that the evidence thus far brought forward indicated that 
caffeine exerts a double influence upon the frog’s heart,—in small doses 
stimulating it and increasing its work, and in larger doses paralyzing it. 
The experiments of Dr. H. G. Beyer ( Amer. Journ. Med. Sci., July, 
1885) confirm this view, showing that caffeine in small doses renders 
contraction of the heart of the terrapin stronger and increases the 
work done, but in larger amounts diminishes both the rate and the work. 
Dr. Beyer, testing the effect of caffeine upon the rate of the circulation, 
found an increase in the outflow, and believes that the alkaloid causes 
a slight dilatation of the arteries; but this conclusion must be received 
with much reserve. 

"Upon the heart of the mammal, so far as can be judged from the 
present evidences, caffeine acts more powerfully than upon that of the 
frog. Leven found that in the first stages of the toxremia both the 
pulse-rate and the arterial pressure are markedly increased. In a series 
of experiments upon dogs, Aubert ( Pfluger's Archiv , v. 612) found as 
an almost constant effect that the drug produced an increase in the 
pulse-rate with a marked lessening in the height of the pulse-wave. 
There was also marked fall of the arterial pressure, which, with the 
small pulse-wave, Aubert believed to be the result of the direct action 
of the drug upon the heart-walls themselves. These experiments were 
made with very large amounts of the alkaloid injected into the jugular 
vein, in most cases the animal being kept alive by artificial respiration. 
In one experiment there was a very distinct rise of the arterial pressure 
(i loc. cit., p. 615). 

Professor Binz (Arch. f. Exper. Path. u. Pharm ., ix. 36) made two 
experiments upon dogs: in one of them the alkaloid was given after 
section of the vagus. In each case there was a very distinct rise 
of the arterial pressure. Maki made a number of experiments, and 
found that large doses were followed by a distinct fall of the arterial 
pressure. In most cases he failed to obtain a first rise of the arterial 
pressure; but, as his experiments were made upon animals that had 

24 


370 


GENERAL REMEDIES. 


been chloralized or atropinized, they are of comparatively little value. 
Aubert (loc. cit ., pp. 617-18) found that after section of the vagi the 
frequency of the pulse was still increased by catfeine, and that galvani¬ 
zation of the nerve failed to arrest the heart’s action. The most im¬ 
portant evidence indicative of a stimulant effect upon the heart is 
furnished by Leven (loc. cit., p. 184), who asserts that after he had 
divided the pneumogastrics and sympathetics, and isolated the heart 
from all connection with the nerve-centres, an administration of caffeine 
increased both the heart-pressure and the pulse-rate. 

This summary comprises all the experimental evidence that we have 
in regard to the action of caffeine upon the circulation. It is very evi¬ 
dent that at present no positive conclusions can be reached from it, 
and that further researches are imperatively demanded. 

The only case of poisoning by caffeine I have met with is reported 
by Dr. C. H. F. Routli (London Lancet , 1883, i. 680). An adult took a 
drachm of the pure citrate. The symptoms developed at once; they 
were burning in the throat, giddiness, faintness, nausea, numbness and 
tremors of the extremities, pain in the stomach and bowels, profuse 
diuresis, and finally collapse, with great cardiac oppression and icy 
extremities. Consciousness was not impaired, and there was no head¬ 
ache until the patient began to recover. 

In a case reported by Dr. Curschmann (Deutsche Klinik , 1873, 377), 
a woman, in order to produce an abortion, took a decoction made from 
about eight ounces of freshly-roasted coffee. Two hours later she was 
found in a condition of great anxiety, with a sensation of intense need 
for air ; she was exceedingly restless, and continually attempted to get 
up from her chair, but was powerless to do so. All the extremities, 
but especially the hands, were affected with very pronounced choreic 
tremors. She knew persons and her surroundings, but her cerebration 
was very much affected, and the next day she remembered nothing 
that had happened at this time. The respiration was quick, twenty- 
four and twenty-five per minute, and short; the pulse one hundred 
and twelve; the heart-beats very strong, even violent. One hour after 
the ingestion of the dose violent diarrhoea set in, and continued until 
the next day. The passages were very thin and watery, with but little 
violent pain, but much tenesmus. There was also marked tenesmus of 
the bladder. The urine was greatly increased in quantity, with the 
specific gravity of 1014. 

Effects of Therapeutic Doses. — The peculiar wakefulness, the in¬ 
creased mental activity, and the nervous restlessness which are induced 
by strong coffee are familiar phenomena to almost every one. They 
are without doubt largely, if not altogether, due to the caffeine con¬ 
tained in the beverage. By doses of two or three grains of the alka¬ 
loid a very similar state of body and mind is induced. Lehmann found 
that eight grains of caffeine produced increased frequency of the pulse, 
very frequent urination, tremulousness, excited mental action, passing 


CARDIAC STIMULANTS. 


371 


into a form of delirium, with confusion of thought, visions, and finally 
a deep sleep. About two hours after taking twelve grains, Dr. Pratt 
was seized with intense physical restlessness, conjoined with a very 
uneasy condition of the mind; very marked general muscular trem¬ 
ulousness soon followed, and the mental anxiety increased. After 
this passed off, there was obstinate sleeplessness, with active and per¬ 
sistent thinking, and frequent urination. The increase of brain-power 
which has been noticed by various observers after caffeine, as well as 
after coffee, tea, guarana, and all the allied crude drugs, is undoubtedly 
real, and must be due to a direct stimulant action exerted upon the 
cerebrum. The experiments made upon animals with toxic doses indi¬ 
cate very strongly that the physical restlessness and tremulousness are 
due to spinal stimulation and are the counterpart of the convulsions 
which toxic doses produce. 

It appears to me that the cerebral stimulation of caffeine differs from 
that of opium in that it affects the reasoning faculties at least as pro¬ 
foundly as it does the imagination. Coffee prepares for active work 
both mental and physical, opium rather for the reveries and dreams of 
the poet. 

Diuretic Action .—In poisoning by caffeine great increase in the se¬ 
cretion of urine is a common symptom, and the statement of Professor 
Gubler ( Bull. Therap., xc. i. 523), that the alkaloid is one of our most 
powerful and certain diuretics, has received abundant confirmation. 
The effect of the drug upon healthy men would indicate that in dropsies 
it does not act simply by regulating the circulation of the kidney, but 
has also a distinct effect upon the renal organ itself. That this surmise 
is correct is proved by the experiments of W. von Schroder and of A. 
Langgard ( Centralbl. f. Med. Wissen ., 1886; also Arch. f. Exper. Path., 
xxii., 1887), who separately found that when a canula was inserted into 
the ureters in an animal whose vaso-motor system was completely para¬ 
lyzed by chloral, injections of caffeine into the circulation caused a very 
great increase in the urinary secretion. Langgard found that usually 
before the great increase of diuresis the urinary secretion was arrested 
for several minutes. This is in exact accord with the experiments of 
Dr. C. D. T. Phillips (International Med. Congress , Washington, 1887) 
made with Eoy’s oncometer. It was found that immediately after the 
injection of a small dose of caffeine, when the blood-pressure was either 
slightly depressed, elevated, or unaffected, the kidney underwent a 
very distinct contraction of its volume, which lasted for two or even 
three minutes and was accompanied with great lessening or arrest of 
the urinary secretion. After the contraction the kidney rapidly ex¬ 
panded beyond its original bulk, and at the same time the urinary 
secretion became excessive. These various experiments prove that the 
action of caffeine upon the renal secretion is entirely independent of its 
influence upon the general circulation. Dr. Phillips’s facts do not, 
however, as he seems to think, prove that the diuresis is caused by the 


372 


GENERAL REMEDIES. 


increase in the flow of the blood to the kidneys. It is more probable 
that the condition of the local blood-vessels is the result of the action 
of the drug upon the renal secreting organ; especially is this the case 
since Schroder found that the division of all the renal nerves did not 
prevent the increase of the secretion under the action of caffeine. 
Because the secretion from the uninjured kidney was increased much 
more than from the kidney whose nerves were destroyed, Professor 
Schrdder believes that the drug increases diuresis by acting both upon 
the nerve-centres and upon the secreting structure of the kidney. To 
my thinking, however, the direct injury to the secreting apparatus of 
the kidney by division of the renal nerves is sufficient to account for the 
difference between the influence of the alkaloid upon the normal and 
the operated-upon kidney, without necessitating the theory of a two¬ 
fold action. Professor Schroder found that there was an increase not 
only of the liquid, but also of the solids of the urine. 

The enormous use made by mankind of substances containing caffeine 
indicates that in some way it is directly of service in the wear and tear 
of daily life. It is not probable that any of the caffeine is assimilated, 
but it is thought by some authorities to check very greatly the elimi¬ 
nation of nitrogen, or, in other words, to lessen the waste of tissue. This 
subject was laboriously investigated by Julius Lehmann in 1853, and 
by F. W. Bocker in 1854, and earlier. Dr. Lehmann found that the 
exhibition of six grains of caffeine daily, the regulated diet being uni¬ 
form, diminished the elimination of urea from twelve to twenty per 
cent. Upon experimenting with the empyreumatic oil of coffee he 
found that it lessened even to a proportionately greater extent the 
elimination of urea, and also acted very powerfully in producing sleep¬ 
lessness, so that the favorite beverage is by no means dependent upon 
its contained caffeine for all of its activity. Dr. Bocker published his 
researches on coffee in 1849 ( Beitrage zur Heilkunde , Bd. i.), but I have 
never seen any abstract of the article, other than the statement that 
he found that the drug causes diminished elimination of urea. His 
investigation of the effect of tea was most elaborate and laborious 
(.Archiv der Vereins fur Gemeins. Arbeiten z. Forderung d. Wissen. Heil- 
kunde, Bd. i. p. 213). He analyzed the faeces, the urine, and the prod¬ 
ucts of respiration, and found, a similar diet being maintained, that 
tea did not affect sensibly the elimination of carbonic acid from the 
lungs, but did very decidedly diminish the excretion of urea, and also 
of nitrogenous matters in the faeces. He then tried abstaining from 
food for periods of thirty-six hours, with and without the use of tea, 
with results perfectly in accord with those just stated. The results 
obtained by various experimenters are singularly discordant. Henri 
Hoppe ( Deutsche Klinik, 1857), in experiments upon a dog, found that 
coffee diminishes very slightly the urea-elimination, but greatly in¬ 
creases the output of carbonic acid. In regard to urea, Rabuteau and 
his pupil Eurastratiade, working with coffee upon men and dogs, ob- 


CARDIAC STIMULANTS. 


373 


tained results similar to those of Bocker ( Comptes-Rendus, 1870, lxxi. 
426, 732), as did also Hammond in this country. On the other hand, 
C. G. Lehmann ( Lehrb. d. Pliysiolog. Chemie , Bd. i., Leipsic, 1842), Yoit 
( Untersuchungen , Munich, 1860), and Koux (Arch, de Physiol. Norm, et 
Path., 1874, i. 592) found that caffeine or coffee sensibly increases the 
elimination of urea, or, in those accustomed to the daily use of coffee, 
has no influence. 

In a long series of experiments upon dogs by MM. Couty, Guimaraes, 
and Hiobey, it is affirmed as a uniform result that the use and assimi¬ 
lation of nitrogenous food were greatly increased, that the carbonic acid 
and oxygen in the blood were markedly decreased, and that the pro¬ 
portion of sugar and of urea in the blood was notably increased ( Comptes - 
Pendus Soc. Biol., v. 546; Comptes-Rendus de VAcad., xeix. 86). 

In the present state of the evidence a positive conclusion can scarcely 
be reached; but I am strongly inclined to believe that the habitual use 
of moderate amounts of tea or coffee has practically no effect upon 
tissue-waste. 

Elimination. —According to the experiments of Bichard Schneider 
( Ueber der Schicksal des Caffeins, etc., Dorpat, 1884), caffeine, when taken 
in therapeutic doses, is entirely destroyed in the system, and, when in 
toxic amount, is partially destroyed and partially eliminated by the 
kidneys. 

Therapeutics. —In accordance with its physiological action, caffeine 
is employed in practical medicine as a cerebral and cardiac stimu¬ 
lant. It is often taken to produce wakefulness and increase the power 
of labor during excessive work. It is a valuable remedy for the relief 
of migraine and other forms of nervous headaches, in which its effects 
are sometimes marvellous, although more often it fails to accomplish 
good. To predict in any case what its influence will be, in the present 
state of our clinical knowledge, is impossible; but the remedy may 
always be tried in safety in the dose of five grains, taken when the 
paroxysm is coming on, and repeated in half the quantity once in 
forty minutes if necessary. In opium-poisoning, either in the form of 
unlimited quantities of a strong decoction of coffee or of the alkaloid 
itself, it is a standard remedy, but, so far as I know, Dr. J. Hughes 
Bennett (Brit. Med. Journ ., 1874, p. 697) has made the only attempt 
to establish by exact experiments the asserted antagonism of caffeine 
and opium. That observer found that the exhibition of from four to 
four and a half grains of caffeine would save a proportion of cats 
poisoned with the previously-ascertained minimum lethal dose (1-J gr.) 
of morphine. Several of the cats which had thus been saved succumbed 
some days afterwards to one and seven-eighths grains of morphine. 
The caffeine was powerless to save animals to which larger doses of 
the narcotic had been given: so that it is fair to conclude that caffeine 
is within narrow limits antagonistic to the narcotic alkaloid. 

Caffeine is very valuable as a cardiac stimulant in the treatment of 


374 


GENERAL REMEDIES. 


all forms of heart-failure. When given to healthy men it decreases the 
rate and markedly increases the force of the pulse. The original state¬ 
ment of Professor Gubler ( Bulletin Therap., xci. 523) that it acts as a 
powerful diuretic is also undoubtedly correct. The indications for its 
employment are precisely those which call for the use of digitalis. It 
differs, however, from that drug in the promptness and fugaciousness- 
of its action, and in being a more certain diuretic. It is, therefore, 
especially useful when there are pronounced dropsical symptoms. In 
chronic Bright's disease it is often of service, especially in the latter 
stages, when there is marked cardiac failure. In acute Bright’s disease 
it should be employed with caution, if at all. It is superior to digitalis 
in never disagreeing with the stomach and in having no distinct cumu¬ 
lative tendency. In some cases, however, it produces obstinate wake¬ 
fulness, and I have occasionally found it necessary to give it solely in 
the early part of the day. It is usually best to commence with a dose 
of four grains, given twice daily, increased if necessary to twenty or 
twenty-five grains a day. For internal administration the so-called 
citrate of caffeine, which is officinal in the British Pharmacopoeia, is 
superior to the alkaloid itself, as more soluble. When great prompt¬ 
ness of action is required, as in cases of sudden collapse or of sudden 
cardiac failure, the hypodermic use of caffeine suggests itself. Unfor¬ 
tunately, the ordinary salts are decomposed in the presence of water, 
and are, therefore, ineligible for hypodermic use. The double benzoate 
of sodium and caffeine has been proposed as moderately stable and 
free from irritating properties. One equivalent of salicylate of sodium 
(160) will also cause the solution of one equivalent of caffeine (244), 
and the following formula has been commended by M. Tanret for 
hypodermic use: Salicylate of sodium, 31 parts; caffeine, 40 parts; 
distilled water, 60 parts. 

CONVALLARIA MAJALIS. 

In 1859 G. F. Walz discovered in the lily of the valley two active 
substances, Convallarin and Convallamarin. Of these the first is crys¬ 
talline, insoluble in water, and, according to Dr. W. Marine ( Schmidt's 
Jahrb., Bd. cxxxiv. S. 166), when taken in doses of three or four 
grains, acts as a simple purgative. The glucoside convallamarin is 
soluble in water, and is the principle to which the plant owes its 
action upon the circulation. Marine found that it kills by a direct 
action upon the heart, and in moderate doses first slows and then 
quickens the pulse: previous division of the vagi did not interfere 
with the development of these phenomena. The chief studies upon 
the physiological and therapeutic action of the lily of the valley are 
those of Professor Germain See (Bull, de l'Acad, de Med., No. 27, 1882, 
p. 767) and of S. Isaew ( Hoffmann und Schwalbe's Jahrb., 1883, 122, 
from the Russian). Professor See finds that in the dog it first slows 
the action of the heart and increases the blood-pressure decidedly, the 


CARDIAC STIMULANTS. 


375 


respirations at the same time becoming fuller and a little less frequent. 
If a toxic dose has been given, the heart’s beats become very rapid and 
irregular, the arterial pressure still being much above normal; finally 
the pressure begins to fall, the cardiac pulsations to grow more feeble, 
and death occurs through syncope. It is stated that the pneumogastric 
nerves are weakened, but never paralyzed, while the general nervous 
system is not affected. In man the action of the drug upon the cir¬ 
culation is as in the lower animals, and there is said to be usually 
produced profuse diuresis and sometimes purging. In Isaew’s ex¬ 
periments upon frogs with convallamarin, the heart was arrested in 
ventricular systole by two milligrammes of the pure convallamarin, 
the frog continuing to live for a long time, the remedy seemingly 
having no effect upon its general nervous or muscular system: iso¬ 
lating the heart had no effect upon the action of the poison. In the 
dog the phenomena of convallamarin-poisoning were as described by 
Professor See, it being further noted that the pneumogastries were not 
affected, that the pulse was often dicrotic during the stage of rapid 
cardiac action, and that the final arrest was diastolic, the heart-muscle 
not being able to respond to the most powerful galvanic stimulation. 
Dr. I. Ott has found that the cardiac arrest in the dog is systolic ( Ar¬ 
chives of Med., Feb. 1883). In Drs. Coze and Simon’s experiments 
the frog’s heart was rendered slow and extraordinarily full in its beat 
and finally arrested in systole (Bull. Gen. Therap., cv. 494). G-. Leu- 

buscher ( Zeitschr. f. Klin. Med., vii. 582) finds that convallamarin pro¬ 
duces in the frog progressive palsy, with cramp-like tremblings and 
death from systolic cardiac arrest; in the mammal, violent convul¬ 
sions and death from diastolic heart-arrest; that it slows the heart¬ 
beat in the mammal, and causes arhythmical contractions, but in no 
dose elevates at any time the arterial pressure. The evidence seems to 
be so contradictory as to suggest that different observers have used 
different principles under the one name. The difficulties of the sub¬ 
ject are rather increased than diminished by the recent researches of 
Leo Lowenthal (Thesis, Wurzburg, 1885), who, using the same prepa¬ 
ration in exactly the same manner and dose upon different frogs of the 
same species, obtained diverse results which he himself was at a loss 
to explain. The Russian J. Nathanson (Bond. Med. Bee., July 15, 
1887) claims that the confusion is largely due to the impurity and 
lack of genuineness in the products used, even M. Merck himself 
having admitted that his commercial convallamarin is not the pure 
principle. Nathanson found that convallarin produced in man when 
given in doses of 0.06 to 0.12 gramme three or four times daily only 
nausea, diarrhoea, and gastric pain; while convallamarin administered 
in daily amounts gradually increasing from 0.03 to 0.3 gramme reduced 
the rate of the pulse and markedly increased the flow of urine, only in 
very rare cases causing nausea or vomiting. 

The lily of the valley is said to have been long used by the Russian 


376 


GENERAL REMEDIES. 


peasantry for the relief of dropsy, and in 1880 Drs. Troitzky and Bojo- 
jawlewskv called attention to it as a valuable remedy in cardiac val¬ 
vular disease, especially when associated with dropsy {Vratsch, 1880, 
47). Professor See recommends it in palpitation of the heart, in car¬ 
diac dilatation, fatty degeneration, and other forms of cardiac weak¬ 
ness, also in valvular lesions with failing heart-power; in a word, in 
the class of cases in which digitalis is now used. When there is dropsy, 
its very positive diuretic action renders it especially valuable, and in 
some cases it purges freely, probably through the convallarin. The 
value of the remedy has been confirmed by Professor H. Desplats 
( Journ. des Sciences Med. de Lille, Oct. 1882), and by several other 
practitioners. Although condemned after trial by Dr. B. Stiller 
( Wien. Med. Wochenschrift, Nov. 1882), by Pel ( Centralhl. f. Therapie, 
1883), by Leyden ( Deutsch. Med. Wochenschr., Feb. 1883), by Jacobi 
and Lubilinski ( Sitzungsb. der Yereins fur innere Med., 1883), and by 
G. Leubuscher, it has been highly praised by Professor Silvestrini 
{La France Med., October, 1883) and by E. Maragliana ( Centralhl. f. 
Med. Wissens., 1883, p. 43). Dr. E. Sansom ( Lond. Lancet, vol. i., 1886) 
gives as the result of his experience that convallamarin is very useful 
in mitral stenosis with failing of the heart. Dr. Marine found that the 
fatal dose of convallamarin was, for the dog, 0.015-0.03 gramme; for the 
cat, 0.005 gramme; for the rabbit, 0.006-0.008 gramme. Professor See 
gives, of an aqueous extract of the whole plant, from fifteen to twenty- 
three grains a day; Bojojawlewsky, each day an infusion representing 
from fifty to one hundred grains of the plant. 

STROPHANTHUS. 

Strophanthus is a genus of tropical apocynaceous climbing shrubs, 
the seeds of several species of which have been used by the natives 
of Africa as an arrow-poison. The pods of at least one of these spe¬ 
cies, stripped of their outer covering, have found their way into com¬ 
merce. The seeds within the pod are abundantly provided with very 
long, deciduous hairs, which are apt to be shed within the pod itself, 
and are so numerous as to weigh nearly as much as the seeds. A 
chemical analysis of these seeds has yielded a crystalline principle, 
which is probably of the nature of a glucoside. Strophanthin in its 
latest form, as obtained by Professor T. R. Fraser, is intensely bitter, 
freely soluble in water, and resolved by the action of mineral acids 
into glucose and a substance to which the name of strophanthidin 
has been given. The name of Strophanthus Kombe has been given to 
the species which is believed to yield the Kombe poison, but it is prob¬ 
able that other species of the genus have similar properties and are 
similarly used by the natives of Africa, and that their seeds will enter 
commerce with those of the Strophanthus Kombe. 

Physiological Action.—T he first experiments with the Kombe 
arrow-poison were those of Professor T. R. Fraser {Journ. Anat. and 


CARDIAC STIMULANTS. 


377 


Phys., vol. vii. p. 141). One-twentieth of a grain of the extract of the 
seeds produced in the frog stiffness of the limbs, gradual loss of reflex 
sensibility, arrest of the heart in systole, and after a time complete loss 
of voluntary movement, the respiration continuing for a length of time 
after the cessation of the heart’s beat. When the poison is brought 
in direct contact with the muscles its influence is immediate, and when, 
in Fraser s experiments, the muscles of a leg were protected from the 
poisoning by tying the arteries, galvanization of the nerve caused 
active contractions at a time when muscles elsewhere failed to respond 
to any irritation of their nerves or substance. The first influence of 
the poison upon the muscular fibre is to increase its tonicity, and when 
the muscle dies it does not go into relaxation, but passes directly from 
life into post-mortem rigidity. K. 1ST. Bahadhurji (Brit. Med. Journ ., 
vol. ii., 1887) affirms that preceding the condition of paralysis there 
is a stage of hypersesthesia, and that the paralysis of voluntary move¬ 
ment and of respiration is due to a direct action of the poison upon the 
muscles themselves; but he is in opposition to Fraser in stating that 
the motor nerve-trunks are also affected. 

That Kombe acts upon the heart of the frog directly has been 
abundantly proved by Dr. Fraser (loc. cit., also Brit. Med. Journ., vol. 
ii., 1885) and by Bahadhurji, who found that the poison affects the 
isolated frog’s heart precisely as it does when injected into the unin¬ 
jured animal. Dr. Fraser noted that after death both voluntary mus¬ 
cles and cardiac muscles are rigid, with an acid reaction. The muscle 
of the frog’s heart, however, is much more susceptible to the action of 
strophanthus than are the voluntary muscles. The available infor¬ 
mation as to the influence of strophanthus upon the mammalian circu¬ 
lation is both insufficient and contradictory. Dr. Fraser affirms that 
it causes a marked increase of the arterial pressure, while Bahadhurji 
states “ that blood-pressure tracings show no appreciable rise.” Fraser 
believes that the drug has little or no influence upon the blood-vessels, 
but Bahadhurji asserts that the blood-vessels seem to be contracted 
under its influence,—a statement which is in direct contradiction to 
his own assertion that the blood-pressure tracings show no appreciable 
rise. If strophanthus produces a rise of the arterial pressure, it prob¬ 
ably acts upon the muscular fibres of the blood-vessels as it does upon 
those of the heart. 

No very elaborate experiments have been made with strophanthus 
upon healthy men, but Professor Drasche obtained, in about three 
hours after five drops of the tincture, a fall of from eight to twelve 
beats per minute of the pulse. After ten drops the pulse fell in half 
an hour twelve to twenty beats; after twenty drops, thirty beats: thero 
was no alteration of the respiration, but a slight fall of temperature. 
A hypodermic injection of fifteen drops of the tincture produced much 
local irritation, repeated vomiting with nausea, copious secretion of 
urine, and a fall of the pulse-rate. 


378 


GENERAL REMEDIES. 


In many cases of cardiac disease strophanthus has produced a great 
increase in the renal secretion; but Bahadhurji states that it does not 
increase diuresis in rabbits, and Zerner and Loaw affirm that it causes 
no increase of the urinary secretion in healthy men. These observa¬ 
tions, if correct, prove that the diuretic action of the drug in disease 
is the result of an increased blood-supply to the kidneys, a conclusion 
which is affirmed by the oncometric experiments of Dr. Phillips ( Trans. 
Internat. Cong., Washington, 1887), who found that the drug does not 
distinctly affect the size of the kidneys. 

Summary .—Strophanthus is primarily a muscle-poison, and probably 
has little influence upon the nerve-centres or nerve-trunks. In the frog 
and in all probability also in the mammal it acts directly upon the 
heart-muscle, causing in moderate doses increased functional activity, 
and in overdoses tetanic arrest. Its action upon the blood-vessels is 
not positively known, but it probably affects the muscles in their walls 
as it does the heart-muscle. 

Therapeutics. —Strophanthus has been employed by a sufficient 
number of careful clinical observers to prove its value in practical 
medicine. The indications for its administration are precisely similar 
to those which call for the use of digitalis. In cases of cardiac weak¬ 
ness a single dose usually produces in from half an hour to an hour a 
fall in the frequency of the pulse with a distinct increase of force, 
effects which last from four to eight hours. If it be correct, as affirmed 
by Professor Drasche, that it has a more stimulant influence on the 
heart than has digitalis, and less of permanent power, strophanthus 
should be useful in the treatment of collapse; but there has as yet been 
no sufficient test of its power in that condition, and the tincture is too 
irritant for hypodermic use. Its influence upon the secretion of urine 
in cardiac disease is affirmed to be remarkable, the urine frequently 
being increased four- or fivefold, and the drug ought a priori to be of 
especial value in cases of pulmonic oedema or severe general dropsy due 
to cardiac disease. When given in overdose it produces burning in the 
oesophagus and the stomach, with gastric distress and severe vomiting, 
but no cumulative action has been yet observed, and the rapidity with 
which its effects come and go makes it highly improbable that it can 
accumulate in the system. Its influence is much less permanent than 
is that of digitalis, and it is not likely to replace that remedy in heart- 
disease, but will rather be used as a succedaneum when a very imme¬ 
diate, temporary effect or a temporary change of remedies is required. 
In one hundred and twenty cases of cardiac disease M. Furbringer 
found it useful in only thirty instances ; and in three cases in which the 
remedy had been used in a large quantity and for a long time, sudden 
death from syncope occurred ( Le Bull. Med., Jan. 22, 1888). I do not 
believe that death was, however, caused by the strophanthus, but think 
it was a parallel occurrence to what often occurs in advanced cardiac 
disease treated with very large doses of digitalis (see page 363). Zer- 


CARDIAC STIMULANTS. 


379 


ner and Loaw ( Wien. Med. Wochen ., 1887) have employed strophanthus 
with alleged success in Basedow's disease and in Bright's disease: they 
consider it especially useful in renal affections with secondary failure 
of the heart, a condition in which I have seen it act most advanta¬ 
geously. 

There is no officinal preparation of strophanthus, but the tincture, 
prepared according to the formula of Professor Fraser, may be given 
in doses of from five to ten drops. Unless the practitioner be ac¬ 
quainted with the individual preparation he is using, the minimum 
dose should always be first employed. To maintain the effect of the 
drug it is necessary to give it at least every eight hours. Professor 
Fraser found that a solution of one part of strophanthin and six million 
parts of water would cause systolic cardiac arrest in the frog in about 
twenty minutes, and Professor Drasche has used it in doses of one 
milligramme three times a day. It is probable that the strophanthin 
used by Professor Drasche was not a chemically pure principle, and 
that the dose of the pure glucoside is less; and until we have a more 
accurate knowledge of the activity of pure strophanthin it must be 
given with the greatest caution. 

SPARTEINE. 

Sparteine is a liquid alkaloid obtained from the Cytisus Scoparius, or 
common broom plant. (See Scoparius.) It is colorless, of a penetrating 
odor and extremely bitter taste, soluble in alcohol, in ether, and in 
chloroform. With sulphuric acid it forms a crystalline salt of a pale- 
greenish color, very soluble in water. 

Physiological Action.— According to Husemann ( Pflanzenstoffe ), 
Mitchell found about four grains of sparteine administered to the rabbit 
to cause a very short stage of excitation, followed by quiet sleep and 
death in three hours, while in Schroff’s experiments a single drop pro¬ 
duced violent convulsions followed by muscular weakness, depression 
of the heart’s action, renewed convulsions, and death. The more recent 
researches of De Rymon, Griffe, and others show that there are two 
stages of sparteine-poisoning: the first of these is characterized by 
trembling, incoordination of movements, increase of reflexes, clonic 
and tonic convulsions, embarrassment of respiration, acceleration of the 
pulse, and enfeeblement of the heart; the second, by enfeeblement of all 
the functions, the respiration becoming more and more depressed, and 
death preceded by convulsions occurring from paralysis of the respira¬ 
tory centres. Dr. Fick found that by artificial respiration life may be 
prolonged for a very considerable period. Fick (Arch. f. Exper. Path, 
und Pharm., 1887) is in accord with Mitchell in stating that sparteine 
affects the cerebrum both of frogs and of mammals, and that it is there¬ 
fore a narcotic, although its paralyzing influence upon the spinal cord 
and upon the motor nerves is dominant. This alleged influence upon 
the motor nerve-trunks appears, however, to be disproved by De Rymon 


380 


GENERAL REMEDIES. 


(Theses, 1880) and by Griffe (These, Lyons, 1886), who are in accord in 
affirming that neither the motor nor the sensory nerves are affected by 
the alkaloid. Indeed, Fick himself states that the fatal arrest of respi¬ 
ration and the loss of reflex activity are chiefly of centric origin, and 
in one place affirms that the motor nerves after death react to a faradic 
current, so that it must be concluded that sparteine has little or no 
influence upon the peripheral nerve. When applied locally to the 
muscles, sparteine has some influence in diminishing their excitability 
and prolonging the duration of the latent period (De Kyrnon, Griffe). 
But it does not destroy the functional activity of the muscles even 
when brought in direct contact with them in a concentrated form, and 
its influence is too feeble to be manifested in general poisoning. 

Dr. Laborde ( Compt.-Rend . Soc. Biolog., Nov. 21, 1885) was the first 
to call attention to the fact that sparteine acts upon the heart, causing 
both in the frog and in the mammal an enormous increase in the size and 
height of the pulse-wave. The subject has been further investigated 
by Griffe ( These 224, Nancy, 1886), by Garand ( These 218, 1886, Lyons), 
by Masius (Bull. Acad. Roy. Med. Belg., vol. i. p. 218), and by Gluzinski 
( Vratch , No. 3, 1887, abstract in Med. and Surg. Reporter, July, 1887). 
According to Griffe, in the isolated heart of the frog sparteine causes an 
extraordinary persistence of contractions; if the dose has been moder¬ 
ate there is an acceleration of the pulse from paralysis of the pneumo- 
gastric centre, followed by a slowing of the heart j if the dose has been 
very large the pulse is rendered less infrequent from the beginning. 
The same investigator found that in mammals small doses accelerate the 
pulse without altering the arterial pressure, and that somewhat larger 
doses cause at first acceleration and then retardation of the pulse. 
After very large doses there is a primary slowing of the pulse, with a 
gradual fall of the arterial pressure in spite of the fact that the cardiac 
waves are extremely large and full. Masius in experiments upon the 
dog obtained results similar to those of Griffe, and calls especial attention 
to the fact that in poisoning during the period of asphyxia the pulse- 
waves are extraordinarily large. Fick, Griffe, Garand, and Masius all 
note that small doses of sparteine weaken, and larger doses paralyze, 
the peripheral portions of the pneumogastric nerves. Fick further states 
that in the heart under the influence of sparteine diastolic arrest can¬ 
not be produced by muscarine, and believes that the inhibitory centres 
in the heart itself are paralyzed. It is certain that sparteine acts upon 
the heart in man as in other mammals, although no cases of human 
poisoning have been recorded. 

According to Legris, sparteine in doses of twenty-five centigrammes 
has no perceptible influence upon the human brain or spinal cord, 
although doses of thirty centigrammes or over cause vertigo, head¬ 
ache, palpitations, and formications in the extremities. After forty 
centigrammes Garand noticed very decided cardiac pain, with sensa¬ 
tions of heat and redness of the face, and loss of power in the legs,— 


CARDIAC STIMULANTS. 


381 


these symptoms commencing about twenty minutes after the ingestion 
of the alkaloid and reaching their maximum in four or five hours. 

The drift of our present evideuce is to show that sparteine does not 
represent the diuretic influence of scoparius. In Griffe’s experiments 
upon rabbits the excretion of urine was absolutely decreased under 
its influence, and the statements of clinicians are in the main con¬ 
cordant in affirming that although in some cases of heart-disease the 
urine has been manifestly increased by the alkaloid, commonly no such 
result is produced : it is scarcely questionable that any increased diuresis 
which may occur is secondary to the regulation of the circulation. In 
some cases intestinal irritation, as indicated by diarrhoea, has been caused 
in man by sparteine. 

Summary .—Our present knowledge is very imperfect, but such facts 
as we have indicate that sparteine acts powerfully upon the cerebral 
and spinal centres as a depressant; that it kills by paralyzing the re¬ 
spiratory centre; that it has a direct influence upon the heart or its 
contained ganglia, by virtue of which at first it increases the force of 
the contraction, but, if the dose have been large enough, finally lessens 
the force; that at first it increases the pulse-rate by paralyzing the 
pneumogastrics, and afterwards diminishes it by acting upon the heart; 
and that it has no pronounced effect upon the kidneys. 

Therapeutics. —The results obtained in the physiological laboratory 
indicate that sparteine is a direct stimulant to the heart, but has no effect, 
at least in therapeutic doses, upon the vaso-motor system. Its applica¬ 
tion to the treatment of disease has been studied by a number of clini¬ 
cians. Professor See affirms it to be of great value in cardiac affec¬ 
tions in increasing the force of the pulse, and especially in producing 
regularity in cases of irregular heart-action. Indeed, he states that 
for the purpose of making an irregular pulse regular it is the most 
powerful remedy known. According to the same observer, the action 
of the drug is usually manifest within an hour after its ingestion, and 
is still perceptible two or three days after the cessation of its adminis¬ 
tration. The value of sparteine in the treatment of failing heart has 
been confirmed by Garand, Poland {Le Poitou Med., 1887), and Yoit 
{Med. Chron., April, 1887). 

Mr. J. M. Clarke {Amer. Journ. of Med. Sci., Oct. 1887), in a paper 
of considerable length, states that in failing heart the symptoms of the 
action of sparteine develop in thirty minutes and continue for five or six 
hours, and consist primarily of a marked retardation of the pulse, with 
increase of the force and of the arterial tension, the skin at the same 
time becoming red and moist, while the respiration, which is at first 
quickened, soon becomes slower and fuller than normal. When taken 
in overdoses he affirms that it causes very high tension of the pulse, 
with sharp cutting pains and throbbing over the heart. In rare cases 
there is nausea. Curiously enough, he further states that when there 
is hypertrophy of the left ventricle sparteine diminishes the force of 


382 


GENERAL REMEDIES. 


the heart. He has employed it with asserted excellent results in mitral 
regurgitation , mitral stenosis , aortic regurgitation , asthma , and various 
functional cardiac derangements. A very important statement which 
he makes is that he has succeeded in controlling the pulse-rate and 
general symptoms in Graves's disease. In opposition to these asser¬ 
tions, Hans Leo ( Zeitschr. f. Klin. Med ., 1887, 142) finds sparteine a 
very uncertain remedy, and the conclusion arrived at by Hiero Stoessel 
(Centralbl. f. Therapie , 1887, 163), that it is inferior as a heart tonic to 
digitalis, and is only to be employed as a succedaneum to that drug, prob¬ 
ably correctly indicates the scope of its influence for good. It has the 
advantage of acting very quickl}’. The commencing dose should not 
be more than the twentieth of a grain, although probably larger 
amounts will be required for decided effect: Clarke gives the dose as 
one-sixteenth to one-quarter of a grain, increased to two grains when 
required. 

ADONIDINE. 

Adonis vernalis, a plant of Northern Europe and Asia, contains a 
glucoside to which Dr. Cervello has given the name of adonidine. Ac¬ 
cording to Cervello, adonidine causes in the frog first increase in the 
force of the systolic contractions, then irregularity of rhythm with long 
diastolic pauses, and finally arrest in violent systole, the most charac¬ 
teristic phenomenon being the peristaltic movements which precede the 
cardiac arrest. According to Dr. H. A. Hare ( Therap. Gaz., 1886, 220), 
adonidine first increases and then slows the rate of the beat in the cut¬ 
out frog’s heart, while its injection into the frog is followed by a period 
of slowing of the cardiac movements, with long diastolic pauses, suc¬ 
ceeded by great increase of the pulse-rate, which in turn gives way to 
slow movement, ending in arrest. Whether the heart be isolated or in 
situ, this arrest is diastolic. The contradiction between these two ob¬ 
servers as to the final arrest is absolute and not readily explained. The 
slowing of the pulse noted by Dr. Hare was found by him to be due to 
stimulation of the pneumogastrics, as it was prevented by their section. 
That the diastolic arrest was not an occasional phenomenon the result 
of excessive inhibition, as is sometimes seen from digitalis, was proved 
by its occurring after section of the vagi, as well as by the fact that 
galvanization of these nerves in the later stages of the poisoning failed 
to affect the heart markedly, they appearing to be paralyzed. 

In Dr. Hare’s experiments adonidine increased very distinctly the 
arterial pressure in the dog, while decreasing the pulse-rate. After large 
doses the first rise is followed by a marked fall of arterial pressure, with 
irregularity of the heart’s action, and finally diastolic arrest. The ex¬ 
periments of Cervello (Arch. f. Exp. Path. u. Pharm., xv.) and of Bub- 
now (St. Petersb. Med. Woch., 1879) are in accord with those of Dr. 
Hare in showing that the drug produces first rise and then fall of press¬ 
ure. Dr. Hare found that in animals whose spinal cord had been pre¬ 
viously cut, a rise of pressure followed the exhibition of adonidine, but 


CARDIAC STIMULANTS. 


383 


was not so great as in the normal dog, so that it is possible that the 
drug acts as a stimulant not only on the heart but also on the vaso¬ 
motor system. The first slowing of the pulse, according to Dr. Hare, 
is the result of stimulation of the inhibitory nerves, since it was pre¬ 
vented by their previous section, while the final fall of pressure is at 
least in part due to the vaso-motor palsy, since neither galvanization of 
the sciatic nerve nor asphyxia had any effect at a time when the heart 
had still considerable power. 

Summary .—What physiological facts we have indicate that adonidine 
acts as a direct stimulant to the heart-muscle or the intra-cardiac gan¬ 
glia, and probably also to the vaso-motor centres, and that in large doses 
it paralyzes both heart and vessels. 

Therapeutics. —In 1879 Adonis vernalis was introduced to the medi¬ 
cal world as a cardiac stimulant by Bubnow, a pupil of Professor Bot¬ 
kin. Since then it has been tested by a number of physicians, with 
fairly concordant results. The general testimony is that its action in 
disease resembles that of digitalis, and that it is useful in the same class 
of cases. It is much more prompt than is digitalis, and Durand affirms 
that it has no cumulative tendency. There has been some difference of 
opinion in regard to its diuretic action, and whatever of such influence 
it has must be attributed to its action upon the circulation in the kidneys, 
rather than to any marked direct power over the secreting structure. 
Durand asserts that it never produces disturbances of the alimentary 
canal, but Lublinski and Huchard have both seen it produce so much 
vomiting or diarrhoea as to require its withdrawal. In a case reported 
by Durand in which by mistake three grains of adonidine were given 
every half-hour, violent vomiting and diarrhoea were the most trouble¬ 
some symptoms. Bubnow employed the infusion made from the whole 
herb 4 to 8 parts in 180 parts of water, and of this he administered a 
tablespoonful every two hours. Durand gives the dose of adonidine 
as 0.02 centigramme (0.3 grain) repeated at intervals of three or four 
hours. 


FAMILY IX—CARDIAC DEPRESSANTS. 


There are certain drugs which are used by practitioners to decrease 
the activity of the circulation; and it is these which are here considered 
under the heading of Cardiac Depressants. Many, in fact all of them, 
possess other powers besides those which cause them to be considered 
under this caption, and none of them are in very close accord in these 
qualities. There is, however, a general resemblance in the action of 
such as are derived from the vegetable kingdom, in that they are all 
depressants to the motor nervous system and yet all produce convulsions. 
I have made an especial experimental study of these convulsions ( [Phila• 
Med. Times , vol. iii.), and have found that they are cerebral and not 
spinal, because they do not occur in any part of the body separated by 
section of the cord from cerebral influence. Further, they are probably 
due to disturbance of the circulation at the base of the brain, for the 
following reasons, the truth of each of which has been experimentally 
determined: first, lessening of the circulation at the base of the brain 
will cause convulsions; secondly, the convulsions produced by the car¬ 
diac depressants do not occur until the arterial pressure is reduced about 
one-half; thirdly, if the disturbance of the cerebral circulation be arti¬ 
ficially increased by tying the carotids previous to poisoning, or in any 
other way, the convulsions come on sooner and are more violent; 
fourthly, in some animals the convulsions caused by arresting circula¬ 
tion at the base of the brain are feeble and ill defined, while in others 
they are violent, and I have found that in species of the first order 
cardiac depressants produce but slight convulsions, while in species of 
the second order they cause violent convulsions. 

The indications for the use of a cardiac depressant may be said to be 
increased arterial excitement, sthenic fevers, and severe local inflamma¬ 
tions. In order that a rational selection of the various drugs may be 
made for any individual case, it is necessary to study how, in these 
various conditions, relief is afforded by an arterial sedative. When 
there is arterial excitement from irritation or excitement of the heart, 
the mode of relief is too obvious to need discussion. It is plain that 
in such a case a drug should be selected which simply depresses the 
heart’s action and does nothing more. In sthenic fever the case is 
different: here it is desirable to relax the peripheral vessels and to pro¬ 
mote a flow of blood to them, while the rapidity and force of the cir¬ 
culation are diminished. A drug which depresses the action not only of 
384 



CARDIAC DEPRESSANTS. 


385 


the heart but also of the superficial vaso-motor nerves is here indicated, 
and if to these powers is added a special one of stimulating the perspi¬ 
ratory glands, the most perfect remedy is obtained. With inflammation 
the effect desired is a lessening of the flow of blood to the part. A 
simple cardiac depressant may do this, by lowering the force of the circu¬ 
lation, but a cardiac vaso-motor depressant is far more powerful. The 
blood-vessels of the inflamed part are already dilated, and consequently 
attract blood, as it were, to the part. If the remedy dilates all the 
blood-vessels, this local attraction ceases, and blood is diverted from the 
inflamed tissue. It would appear from the experiments of Ludwig, 
Schiff, and others (La Nazione, Aug. 1872) that the blood-vessels, after 
complete dilatation, are able to hold twice the normal amount of blood, 
and Golz, quoted by Fothergill (Brit. Med. Journ., 1873), found that 
the intestinal vessels were able to contain all the blood of the body. 
These facts show how by means of an arterial sedative, which paralyzes 
the vaso-motor centres, “ we can bleed a man into his own blood-vessels,” 
or, in other words, get much of the effect of a venesection by drawing 
blood from the diseased part. 

ANTIMONY. 

ANTIMONII OXIDUM. U.S.—OXIDE OF ANTIMONY. 

A grayish-white powder, insoluble in water, wholly soluble in hydro¬ 
chloric or tartaric acid. It is prepared by dissolving the sulphuret of 
antimony in hydrochloric acid, adding nitric acid, and precipitating with 
water of ammonia. Its solution in the stomach is dependent upon the 
acid there present, and consequently, being uncertain in its action, it 
should not be used internally—although it is capable of producing all 
the effects of tartar emetic, for the preparation of which it was intro¬ 
duced into the Pharmacopoeia. Antimonii Sulphidum U.S., Antimonii 
Sulphidum Purificatum , U.S., and Antimonii Sulphuratum, U.S., are still 
more uncertain preparations, whose therapeutic use ought not to be 
encouraged. 

ANTIMONII ET POTASSII TAETRAS. U.S.—TARTRATE OF 
ANTIMONY AND POTASSIUM. 

Tartar Emetic is prepared by boiling the oxide of antimony in a 
solution of bitartrate of potassium. It occurs in the form of a white 
powder, the result of the pulverization of transparent, colorless, slightly 
efflorescent crystals, which are most commonly rhombic octahedrons. 
Its taste is variously described: to me it is at first very slight, but after 
a time styptic and acrid. In some persons it blisters the tongue and 
lips after a few moments of contact. Tartar emetic is insoluble in abso¬ 
lute but soluble in dilute alcohol, soluble in from two to three parts of 
boiling water, and in from twelve to fifteen parts of water at ordinary 
temperatures. It is incompatible with alkalies and with acids, including 
tannic acid and substances containing it. 

25 


386 


GENERAL REMEDIES. 


Physiological Action.— Locally applied, tartar emetic is an irri¬ 
tant, acting upon some very delicate and susceptible skins in a very 
short time. In most instances, however, its continuous application for 
several days is necessary to produce any effect. At first there is simply 
a redness, accompanied by some burning pain and the eruption of small 
papules, which shortly become converted into vesicles and then into 
pustules. These are irregular in shape and size, varying from one- 
eighth of an inch to an inch and a half in diameter, and are very pain¬ 
ful. Sometimes these pustules give rise to small sloughs, but generally, 
if the application be withdrawn, they simply give origin to superficial 
ulcers, which readily heal. 

The only symptoms which are induced by small therapeutic doses 
(one-twelfth of a grain) of tartar emetic when exhibited for a short 
time are a scarcely perceptible diminution of the force of the pulse 
and an increase of the perspiration. 

By somewhat larger amounts of the drug, nausea is induced, accom¬ 
panied in a more decided degree by the phenomena just mentioned. 
After large doses, prolonged nausea, violent vomiting and retching, 
with marked reduction of the force of the pulse, great muscular re¬ 
laxation, and a feeling of faintness, occur. At the same time the 
saliva is generally increased in amount, and the skin is bedewed with 
sweat. 

After poisonous doses all these symptoms are intensified. The 
vomiting is violent, repeated, continuously re-excited by the slightest 
provocation, and is accompanied by burning in the oesophagus and 
stomach and by colicky pains in the abdomen. The matters vomited 
are first mucus, then mucus with bile, and finally, in some cases, blood. 
With the gastric disturbance occurs violent and frequent serous purging, 
the discharges resembling those of cholera, but becoming in some cases 
towards the last bloody. Cramps may occur in the extremities, and, in 
conjunction with the serous purging, have caused the antimonial poi¬ 
soning to be mistaken for cholera. The exhaustion is extreme, and 
deepens into collapse, with thready or imperceptible pulse, pinched, 
livid countenance, suppressed voice, profuse cold sweats, lowered tem¬ 
perature, and at last death from asthenia, generally preceded by stupor 
or convulsions: indeed, Taylor reports cases in which wild delirium 
was present some hours before death. The urine* in mild cases is 
increased in quantity, as it is also in the beginning even in fatal cases, 
but in such towards the close it is generally scanty and bloody, and 
even suppressed. C. Gathgens found, in some incomplete experiments, 
an increase of the elimination of urea after repeated non-toxic doses of 
antimony (Centralbl. f. Med. Wiss. : 1870, 321). 


* What is said in the text is, I think, correct; although authorities differ on this point. 
Trousseau (Traitl de Therapeutique, 4th ed., vol. i. p. 619) affirms that it is suppressed; Huse- 
mann, that it never is suppressed ( Toxicologie , p. 854); Tardieu, that it is scanty. For a case 
in which it teas suppressed, see Taylor’s Medical Jurisprudence , London, 1873, p. 309. 



CA RDIA C DEPRESS A NTS. 


387 


It is evident that the symptoms just enumerated can be best studied 
in detail under several heads. Before entering upon this, however, it 
is well to premise that the experiments of Viborg ( Stille’s Therapeutics, 
vol. ii.), Buchheim, Courten (Ibid.), Magendie (Ibid.), Ackermann (Vir¬ 
chow's Archiv, Bd. xxv. p. 531), Richardson (Lancet, May, 1856), Nobi- 
ling (Schmidt's Jahrbucher, Bd. cxl. p. 24), and Radziejewski (Reichert's 
Archiv, 1871), and of others, have demonstrated that tartar emetic acts 
upon the lower animals precisely as upon man. 

Circulation. —When a sufficient dose of tartar emetic is injected into 
the frog (Radziejewski, Ackermann, Ndbiling), the cardiac contractions 
in a very short time are lessened in frequency and force, and become 
irregular, the auricles pulsating more frequently than the ventricles, 
until finally arrest occurs in diastole. After death the irritability of 
the cardiac muscle to ordinary stimuli is almost, or more frequently 
entirely, destroyed; but in the recent experiments of I. Soloweitschyk 
(Arch.f. Exper. Path. u. Pharm., xii. 440), digitalis placed upon the para¬ 
lyzed heart caused it to recommence its action,—evidence that it is 
rather the excito-motor ganglia than the muscle-fibre which is affected 
by the antimony. Upon the heart of the mammal the drug acts as 
upon that of the frog. According to the researches of Ackermann and 
of Ernst Sentz (Piss. Inaug., Dorpat, 1853), the arterial pressure always 
falls steadily and to an extreme degree. The pulse sometimes seems 
accelerated at first, but in the great majority of cases is decreased very 
decidedly in its rate. During this period of slow pulse the diastolic 
pauses are extremely long, but the individual beat will influence the 
mercurial column of the cardiometer five times as much as normal. 
After a while the pulse suddenly becomes very rapid, the force of the 
heart-beat is almost completely lost, the arterial pressure falls to a 
minimum, and in a very few moments diastolic arrest occurs. It is 
evident that the action of antimony upon the heart is a direct one. 
The irritability of the muscle is lost, and Ackermann has found that 
the cut-out heart of the frog is affected by the solution of tartar 
emetic; further, the experiments of Radziejewski have proved that 
the peripheral ends of the vagi in antimonial poisoning are early more 
or less completely paralyzed, so that the diastolic arrest cannot be 
due to excitation of the inhibitory apparatus.* The depression of the 
heart-muscle power does not seem, however, to be the sole cause of 
the lowering of the blood-pressure, for Soloweitschyk has found that 
galvanization of the vaso-motor centre with a powerful current is 


* Perhaps the present is as fitting as any other place to notice the theory of Nobiling, 
that the action of tartar emetic upon the heart is owing to the potash it contains. This theory 
in itself is so improbable that it would seem scarcely worthy of discussion, were it not for the 
fact that Nobiling asserts that the tartrate of antimony and soda is not poisonous. Dr. Rad¬ 
ziejewski ( loc. cit., p. 485) has repeated and extended the experiments of Nobiling and com¬ 
pletely disproved both the asserted fact and the theory based upon it, showing that the soda-salt 
is as poisonous as the potash-salt. 



388 


GENERAL REMEDIES. 


powerless to produce any elevation of the arterial pressure at a time 
when the heart still responds to stimuli. Moreover, the fall of the 
arterial pressure occurs at a time when the heart is apparently beating 
with more than its normal force. The conclusion is reached that anti¬ 
mony lowers arterial pressure by a direct action upon the heart and the 
vaso-motor system , and that it is probably the peripheral portions of the 
latter system which are affected. 

Nervous System. —A prominent symptom in antimonial poisoning is 
paralysis, affecting to an extraordinary degree the sensory and to a less 
extent the motor system. In man the anaesthesia which occurs in ani¬ 
mals has been overlooked, but in the advanced stages of poisoning it is 
no doubt present. Radziejewski and Soloweitschyk have found that 
the depression of reflex activity occurs after section of the cord, and 
is therefore not due to stimulation of the Setschenow inhibitory centre; 
that it is not prevented by tying an artery and cutting off access of the 
poison to the nerve, and is therefore not peripheral. It consequently 
must be spinal; and, as both observers noted that in the frog and the 
rabbit voluntary movements persist after the total abolition of sensi¬ 
bility and of reflex activity, the conclusion is reached that antimony 
is a paralyzant to the receptive centres or sensory tract of the spinal cord. 

Radziejewski states that sensibility is first lost towards thermic and 
chemical irritants, and then towards tactile stimuli. The motor nerves 
and muscles are said to retain their functional power. 

Temperature. —The influence of antimony upon the temperature ap¬ 
pears not to be very marked when the drug is exhibited in ordinary 
therapeutic doses. Thus, Ackermann found that, after doses severe 
enough to induce violent vomiting, no alteration in the temperature 
could be discovered by the thermometer under the tongue. Owing, no 
doubt, to the disturbance of nervous and arterial action, there is in 
these cases, however, a very marked reduction of the temperature of 
the extremities. Thus, in the cases just alluded to (Ackermann) the 
heat of the hands was lowered from 0.2° C. to 3.5° C. in various per¬ 
sons. This decrease of the temperature is certainly in a measure due 
to increase of the heat-evolution. 

After poisonous doses of antimony the decrease of animal heat is 
very perceptible, provided the victim live sufficiently long. Thus, in 
Ackermann’s experiments a fall of only 1.6° C. occurred in rabbits 
killed in the hour, but in those that lived five hours the depression 
amounted to 6.6° C. 

Abdominal Organs. —It cannot be gainsaid that tartar emetic acts as 
an irritant upon the alimentary mucous membrane. Although cases 
(Archives Gen., Sept. 1865) have been reported in which no lesion has 
been found in the stomach or bowels after death from antimony, yet 
in the great majority of instances very decided indications of violent 
inflammation have been present. 

Dr. Radziejewski, on the strength of this action, and of two experi- 


CARDIAC DEPRESSANTS. 


389 


ments in which he found the greater portion of the ingested antimony 
in the vomit of the patient, has advanced the theory that the emesis is 
due to a local action of the drug. The persistent nausea, however, 
certainly indicates that the remedy does not act like the so-called me¬ 
chanical emetics. Further, the vomiting induced in the experiment 
of Magendie, of replacing the stomach of an animal by a bladder and 
giving tartar emetic, would seem at first sight to settle the point com¬ 
pletely. This experiment of Magendie has been confirmed by Brinton 
(Cyclopaedia of Anatomy , Supplement, p. 319 ; Lancet , 1853, vol. ii. p. 
599), who further proved that when tartar emetic was injected into 
the vein of an animal it was very freely aud rapidly eliminated by the 
stomach. Dr. B. W. Bichardson ( Lancet , vol. i., 1856) has corroborated 
this, and has also found that a similar elimination follows the inhalation 
of antimonietted hydrogen. I think, therefore, it must be conceded— 
first, that the finding of even a large quantity of antimony in the vomit 
does not prove that its action on the stomach is chiefly a local one ; sec¬ 
ondly, that the emesis is certainly preceded by at least a partial ab¬ 
sorption. This would seem to show that the emesis is purely centric. 
The experiments of Mooso ( Schmidt's Jahrb., clxix. 236), on the other 
hand, indicate that the local action of the drug is a powerful factor in 
the production of the vomiting. It was found that when tartar emetic 
was administered by the mouth vomiting was caused by smaller quan¬ 
tities and more promptly than when injected into the veins; also that, 
after section of the peripheral vagi in the abdomen, a reverse relation 
existed between the two methods of administration. If these experi¬ 
ments be, as they appear, correct, tartar emetic must cause vomiting 
partly by an action on the centres and partly by a local influence upon 
the stomach. The purging induced by tartar emetic is seemingly an 
effort at elimination. 

Respiratory Organs. —The respiration in poisoning by antimony is 
very irregular, with all sorts of variations in the rhythm of the act. 
In the advanced stages the pauses are often very long, and the inspi¬ 
ration and expiration so forced and prolonged that veiy generally, in 
animals at least, marginal emphysema and subpleural ecchymoses are 
found after death. The origin of the respiratory trouble is probably 
somewhat complex, the chief factor being the direct influence of the 
drug upon the respiratory nerve-centres, and minor causes the intense 
venous congestion due to the failure of the circulation, and the altera¬ 
tion of the blood itself. Upon the mucous membrane of the lungs 
antimony acts directly or indirectly, even in moderate doses, as is 
shown by clinical experience and by the experiments of Mayerhofer 
(.NothnageVs Arzneimittellehre, Berlin, 1870, p. 219). 

Therapeutics.— There are three indications to meet which tartar 
emetic is constantly employed. The first of these it fulfils by virtue 
of its powers as an emetic. The discussion of this may be found in the 
chapter upon Emetics. 


390 


GENERAL REMEDIES. 


The second purpose for which antimony is used is to depress arterial 
excitement. It is chiefly in inflammation that tartar emetic is used as an 
arterial sedative. In combination with more decided diaphoretics it is 
constantly employed by some surgeons in fever after operations , in gon¬ 
orrhoea, and in various sthenic inflammatory affections. In pneumonia 
it has been very largely used, forming an essential portion of the older 
plan of treating that disease. According to the method of Easori, 
four or five grains a day were at first given, but rapidly increased to 
twenty-four or even thirty grains daily. Although by the aid of opiates 
and careful dilution a species of tolerance was often obtained for these 
heroic doses, yet very properly the plan has been abandoned by modern 
therapeutists. As tartar emetic if administered in sufficient quantity 
to depress markedly the circulation causes generally intense nausea and 
often purging, I think it is inferior to aconite or veratrum viride when 
it is desired to depress the circulation very decidedly in pneumonia or 
any other disease. 

Owing to its action upon the mucous membrane of the bronchial 
tubes, in the first stages of bronchitis tartar emetic is a valuable remedy. 
After free secretion has been established, other expectorants are, I 
think, of more service. The value of antimony as a diaphoretic de¬ 
pends largely upon its action on the circulation. Minute doses of it 
are constantly employed to increase the efficiency of fever-mixtures. 
It must always be borne in mind that it is a powerful depressant, and 
is therefore to be employed only in sthenic cases. 

As a counter-irritant, tartar emetic is used only when it is desired to 
produce a slow, persistent, and at the same time very decided impres¬ 
sion. For further discussion of its application to disease, see the chap¬ 
ter on Eubefacients. 

Toxicology.— The symptoms ordinarily produced by poisonous doses 
of antimony have been sufficiently described. There is, however, 
according to authors, a form of antimonial poisoning in which neither 
vomiting nor purging* occurs, the symptoms being simply intense 
prostration, cold clammy sweat, a sense of oppression in the chest, with 
the respiration at first increased, then diminished in frequency and em¬ 
barrassed; a rapid feeble pulse, after a time becoming slow, intermit¬ 
tent, and irregular; delirium, unconsciousness, tremblings, and clonic 
and tonic convulsions (Husemann, Toxicologie , p. 853). 

Tardieu ( loc. cit., p. 608) states that in some cases of tartar emetic 
poisoning a rash exactly resembling that produced by the external ap¬ 
plication of the drug has appeared all over the body on the fourth or 
fifth day. 

As already stated, in the vast majority of cases there are to be 
found, after death from antimonial poisoning, very decided traces of 


* Husemann states this. Although vomiting is absent in these cases, purging is gener¬ 
ally present. I do not remember to have seen the report of a case in which it was absent. 



CARDIAC DEPRESSANTS. 


391 


inflammation of the stomach and bowels; in some cases, however, these 
appear to he wanting. The venous system is generally very much 
engorged, and the viscera are intensely congested. Magendie asserted 
that in animals poisoned by tartar emetic the lungs are always full of 
portions apparently hepatized; hut Ackermann (loc. cit., p. 544), in 
twenty experiments, found only some marginal emphysema and sub- 
pleural ecchymoses, with, in one or two cases, spots of atelectasis in 
the lungs. The assertion of Magendie, therefore, is too sweeping; but 
it is true that, in a large proportion of fatal cases of antimonial poison¬ 
ing, emphysema, pulmonary apoplexy, atelectasis, or other structural 
lesions of the lungs exist. The blood usually coagulates imperfectly. 

Dr. Salkowsky ( Virchow's Archiv, Bd. xxxiv. p. 78, 1865), of Moscow, 
has found that when animals are fed upon antimonic acid (one-half to 
one gramme daily) or other preparations of the metal for from fourteen 
to nineteen days, the liver, kidneys, and even the heart undergo a fatty 
degeneration; also that there is a lessening of the amount of glycogen 
in the liver, and in some cases even a total disappearance of it. This 
has been confirmed by Professors Grohe and Mosler, who state that in 
the duchy of Brunswick the peasantry give to the geese, when pro¬ 
ducing the famous fatty livers, a certain quantity of the white oxide of 
antimony every day. 

The minimum fatal dose of tartar emetic is not known. Three- 
quarters of a grain in a child, and two grains in an adult, have proved 
fatal; but in the latter case extrinsic circumstances favored the result 
(Taylor, Guy's Hospital Reports , Oct. 1857, an analysis of thirty-seven 
fatal cases); two hundred grains have been recovered from (case, Tay¬ 
lor's Medical Jurisprudence, 1873, p. 309); also one hundred and seventy 
grains (AT. Y. Med. Rec., xxiv. 401). 

Chronic Poisoning. —According to Mayerhofer ( Heller's Archiv , 1846, 
quoted by Taylor), the symptoms following the criminal administration 
of small doses of tartar emetic at intervals are nausea, mucous and 
bilious vomiting, watery purging, often followed by constipation, small 
frequent pulse, and asthenia, deepening into death from exhaustion. 

The treatment of antimonial poisoning consists in washing out the 
alimentary canal with large draughts of tannic acid ,—the best known 
antidote,—and in the use of opium and of internal and external stimu¬ 
lants. 

Administration.— The sudorific dose of tartar emetic is one-twelfth 
of a grain, the emetic dose one-half to one grain, repeated every twenty 
minutes as necessary. The Antimonial Wine ( Vinum Antimonii , U.S.) 
contains two grains of tartar emetic in the ounce. The emetic dose is 
half a fluidounce. The Unguentum Antimonii (tartar emetic, one part 
in five) is employed externally, as a counter-irritant. A small quantity 
is spread upon a linen rag and laid upon the skin, or a little of it may 
be well rubbed in twice a day. Whenever it is persistently used, there 
comes on, sooner or later, a peculiar burning or tingling pain, which is 


392 


GENERAL REMEDIES. 


very shortly followed by pustulation. The effect of the drug is very per¬ 
sistent as well as severe, so that the remedy is applicable only to a few 
cases in which an action of the kind spoken of is required. Care must 
be exercised not to continue the application too long, lest severe and 
obstinate ulceration be produced. 

VERATRUM VIRIDE. U.S. 

The root-stock of Yeratrum viride, a coarse perennial hei’bal plant, 
indigenous to the Northern United States. It is a large tapering rhi¬ 
zome, an inch or two in length, less than an inch in thickness at the 
base, and having a bitter acrid taste. It contains two alkaloids, jervine 
and veratroidine, which are so closely associated with the resin as to be 
separated from it with great difficulty. The nature of these alkaloids 
has been the subject of much discussion among chemists. Mr. Charles 
Bullock was, I believe, the first to separate them one from the other, 
and to prove the inertness of the resin. In accordance with the belief 
of Mr. Bullock that these alkaloids were distinct from all previously 
discovered, Dr. George B. Wood named them viridine and veratroidine. 
Dr. Peugnet subsequently showed that viridine is identical with jer¬ 
vine, previously described by Simon, from Yeratrum album. Mr. Mit¬ 
chell ( Proc. Amer. Pharm. Assoc., 1874) confirmed this, and concluded, 
with Peugnet and Bullock, that veratroidine is distinct from vera- 
trine. In 1876 (Amer. Journ. Pharm., 1876, p. 1) Professor Wormley 
arrived at the conclusion that veratroidine is identical with veratrine. 
Without intending to deny the conclusions of Professor Wormley, I 
shall, in the present edition, allow the text of the old edition to stand, 
so far as concerns the names employed to represent the two alkaloids 
of veratrum viride. Jervine is so closely united with the inert resin 
that it is separated from it with great difficulty. 

Physiological Action.— In treating of the physiological action of 
veratrum viride, I shall first speak of the effects of its alkaloids singly. 
When an animal is poisoned with jervine, the first symptom manifested 
is sluggishness, as shown by a disposition to be quiet, accompanied by 
distinct signs of muscular weakness. In a little while peculiar rapidly- 
repeated thrills run through the muscular system, so that the animal 
trembles violently. After a greater or less length of time the animal 
becomes unable to stand, from weakness, and at or before this period 
violent convulsions appear,—general clonic spasms without rigidity. 
The convulsions alternate with intervals of relaxation, and as the animal 
grows more profoundly prostrated are less severe, but they continue in 
most cases up to death. Even when they are most violent, force is 
evidently wanting. The animal is totally unable to raise himself from 
the ground; the pigeon drives himself forward upon his breast, the 
rabbit pushes himself along on his belly, or lies upon his side and kicks 
into the air. Sensation appears to be benumbed only very late in the 
poisoning, and consciousness is preserved almost to the last. The pupils 


CARDIAC DEPRESSANTS. 


393 


are not affected. There is no purging or vomiting, but always pro¬ 
fuse salivation. Respiration ceases before cardiac action, so that death 
probably takes place from asphyxia. 

The circulation is profoundly affected. The pulse is generally, if 
not always, lessened in frequency, provided the animal be quiet. When 
there are convulsions, or even when the tremors are marked, it becomes 
very rapid. The arterial pressure is greatly lowered, falling progres¬ 
sively from the beginning to the end of the poisoning. The force of 
the individual beat appears not to be much altered at first. 

In an elaborate series of experiments (. Phila. Med. Times , vol. iv.) I 
found that jervine had little or no effect on the pneumogastric nerves , since 
it acts as usual after those nerves have been cut, and galvanization of 
the par vagum in animals profoundly affected by the poison produced 
the usual cardiac results. Further, when the cord was cut very high 
up, so as to paralyze the accelerators, jervine still lessened the pulse- 
rate. As it was also proved that the alkaloid lessens the arterial press¬ 
ure after division of the cord, i.e., after vaso-motor paralysis, and also 
that it paralyzes the heart of the frog or turtle when placed directly 
upon it, it follows that jervine lowers the force and frequency of the car¬ 
diac beats independently of its nerves, by a direct action on the cardiac 
muscle or its contained ganglia. When the nerve-trunks were galvan¬ 
ized in an animal poisoned with jervine, although the pain-cries showed 
that the afferent nerves were not paralyzed, little or no rise occurred 
in the arterial pressure. It seems, therefore, that the jervine not only 
acts on the heart, but is also a powerful depressant to the vaso-motor 
nerve-centres. 

In frogs, as well as in higher animals, poisoned with jervine, there 
is a very marked diminution and finally abolition of reflex activity; 
and, as the functions of neither peripheral nerves nor muscles are inter¬ 
fered with, it is evident that the alkaloid is an intensely powerful 
spinal depressant. The convulsions are cerebral in their origin, as they 
do not occur below the point of section when the spinal cord is divided.* 
Locally, jervine is very feebly if at all irritant. 

The general symptoms induced by veratroidine resemble those caused 
by its congeneric alkaloid, but it is decidedly more irritating than the 
latter, and always induces vomiting, and occasionally purging. In poi¬ 
soning by it there are in most cases some muscular twitchings, and 
finally marked convulsions, but neither of these are so severe and so 
repeated as in the case of jervine. Death takes place from asphyxia, 
due to paralysis of the respiratory muscles. 

Upon the spinal cord, the peripheral nerves, and the muscles, vera¬ 
troidine acts very much as does jervine, being a decided spinal de¬ 
pressant. 

* Some of the conclusions of my first investigation ( American Journ. Med. Set., 1870) of 
this drug were called in question, but I have in my last paper gone over the whole ground 
afresh. The earlier discussion may be found in Phila. Med. Times, vols. ii. and iii. 



394 


GENERAL REMEDIES. 


The action of veratroidine upon the circulation is a very curious 
one. After a hypodermic injection of the poison the rapidity of the 
pulse and the arterial pressure are at first decidedly lessened. After 
a time, the pulse still remaining very slow, the individual heart-beats 
become endowed with a force greatly beyond normal, and the arterial 
pressure becomes normal; then suddenly the pulse-rate becomes very 
rapid, the individual cardiac beats losing much of their extraordinary 
vigor, but the arterial pressure rising nearly fifty per cent, beyond its 
original position. 

When the alkaloid is thrown directly into a vein, these phenomena 
are intensified and abbreviated. I have seen the arterial pressure fall 
to zero in thirty seconds, and in one and a quarter minutes rise to 165 
(110 normal) centimetres. The rise is not due to a direct action of the 
drug, but to the sudden asphyxia which it induces, since it does not 
occur if free artificial respiration be maintained ( Phila . Med. Times , 
vol. iv.). 

When artificial respiration is kept up, veratroidine steadily lessens 
both arterial pressure and pulse-rate. When the par vagum has been 
divided, artificial respiration being maintained, veratroidine is power¬ 
less to reduce the pulse-rate; and when the pulse-rate has been reduced 
by the drug in the uninjured animal, division of the par vagum is fol¬ 
lowed by an enormous rise in the number of cardiac beats per minute. 
These facts certainly prove that veratroidine is a powerful stimulant to 
the inhibitory nerves of the heart. Moreover, I have found that when 
the spinal cord is divided so as to paralyze the accelerator nerves, a 
minute dose of the poison (one-thirtieth of a grain) will at once cause 
diastolic arrest of the heart’s action, but if the pneumogastrics be now 
severed, and the repressive force be thus taken off, the relaxed, seem¬ 
ingly dead viscus recommences its beat. The slow pulse of mild vera- 
troidine-poisoning becomes rapid when a large dose of the poison is 
injected. Further, after a large dose division of the pneumogastrics 
has no effect upon pulse-rate, and the most intense galvanic current 
applied to the peripheral ends of the divided nerves is powerless to 
affect the viscus. Evidently, large doses of veratroidine paralyze the 
cardiac inhibitory apparatus, while small ones stimulate it intensely. 
The paralysis is certainly peripheral; whether the stimulation is cen¬ 
tric or peripheral has not as yet been determined. When enormous 
doses of veratroidine are thrown directly on the heart by venous in¬ 
jection, they at once kill the cardiac muscle. Upon the vaso-motor 
nerves veratroidine in moderate toxic amounts has no demonstrable 
influence. Dr. F. Reigel ( Pfluger's Archiv, 1871, p. 409) has demon¬ 
strated that the rise of arterial pressure which occurs in asphyxia is 
largely due to vaso-motor spasm. In viridine-poisoning asphyxia has 
very little influence upon the arterial pressure, because the vaso-motor 
eentres are paralyzed; in veratroidine-poisoning the slightest inter¬ 
mission in the working of the bellows of the apparatus for artificial 


CARDIAC DEPRESSANTS. 


395 


respiration is followed at once by an enormous rise of the mercury 
in the manometer,—conclusive proof that the vaso-motor centres are 
not seriously affected. This deduction I have experimentally corrobo¬ 
rated by galvanization of a sensitive nerve : always, unless an enor¬ 
mous amount of the alkaloid had been given, the rise in the arterial 
pressure was marked and immediate. In estimating the physiological 
action of veratroidine it must be borne in mind that artificial respira¬ 
tion was maintained during the study of the action of the drug on the 
heart and vaso-motor centres; that its influence on the respiratory 
centres is so intense as to overbalance its cardiac action, and, when 
the animal is left to itself, to cause death before any very decided in¬ 
fluence has been exerted on the heart. The action of the alkaloid may, 
therefore, be summed up as follows: it is a powerful respiratory poison, 
lessening at first the freguency of the cardiac heat by stimulating the pneu- 
mogastrics, but soon losing all control over the heart , owing to the powerful 
influences which the induced asphyxia exerts. 

The resin of veratrum viride, when completely deprived of the alka¬ 
loids, is nearly inert. It seems, however, to be irritating to the digestive 
organs, and very probably aids in the production of the vomiting occa¬ 
sioned by full doses of the drug. 

As the action of the alkaloids of veratrum viride is very similar, 
and as they are the only active principles of the drug, it is very easy 
a priori to determine what the influence of the drug will be. Sufficiently 
numerous experiments* have been performed with the crude drug, or 
its preparations, to show that it acts upon the lower animals as upon 
man; but it is not necessary here to do more than allude to them. 
When taken in small doses by man, veratrum viride first reduces the 
force without much lessening the frequency of the pulse, but after a 
time the pulse falls very much in rapidity, sometimes, according to 
Dr. Norwood, even to thirty-five a minute. 

If any exertion be made during this stage of depression, the slow 
pulse will be suddenly converted into an exceedingly rapid one. The 
slow pulse is sometimes moderately full, but is always very soft and 
compressible; the rapid pulse is exceedingly feeble and small, often 
thready, and may become imperceptible. Severe nausea and vomiting 
accompany or follow the reduction of the pulse-rate. That the latter 
is not due to gastric disturbance is, however, shown by the fact that it 
often precedes the stomachic symptoms, and may exist without them. 
Thus, Professor Percy states that he has seen the pulse reduced to 
thirty per minute without nausea being induced. During the stage 
of depression there is always decided muscular weakness and relaxa¬ 
tion. 

After a poisonous dose the symptoms above noted are increased in 


* See especially paper by Professor S. R. Percy, Trans. Amer. Med. Assoc.: reprinted as 
pamphlet, 1864. 



396 


GENERAL REMEDIES. 


intensity and become very alarming. A running, almost imperceptible 
pulse; a cold, clammy skin; intense nausea, and incessant attempts 
at vomiting, or retching, or hiccough; absolute muscular prostration; 
faintness; vertigo; loss of vision, and semi-unconsciousness, make up 
the group of extreme symptoms. Yarious observers also speak of an 
excruciating prsecordial pain; but this I have not seen. 

Summary. —From these symptoms, with what has already been said 
about the alkaloids, it follows that veratrum viride is a powerful spinal 
and arterial depressant, exerting little or no direct influence upon the 
cerebral centres. In full therapeutic doses it lowers the pulse-rate both 
by a direct action on the muscle (jervine) and by stimulating the inhibi¬ 
tory nerves (veratroidine); it diminishes the force of the heart-beat by 
a direct influence on the cardiac muscle (jervine), and produces a general 
vaso-motor paralysis (jervine) more or less complete according to the 
size of the dose* Under its action the functional activity of the skin 
is greatly increased; but, as this is a necessary result of the profound 
arterial depression, there is no reason for believing that the drug 
has any specific influence upon the perspiratory glands. In a similar 
manner the excretion of bile is often indirectly increased by veratrum 
viride, through the severe vomiting which it induces. 

American hellebore undoubtedly lowers animal temperature very 
decidedly, but whether directly or indirectly has not been determined. 
I have frequently seen it reduce the bodily heat, and M. Linou [Bull. 
Therap., 1869, lxxvi. 95) states that it does so, but not so certainly as 
it lowers the pulse. Oulmont (Bull. Therap., 1868, lxxiv. 153) asserts, 
as the results of his experiments, that in animals from half an hour 
to two hours after the administration of such doses as would produce 
violent symptoms without killing, the temperature fell 2°, 3°, or. even 
5° (C. ?), and remained at this point for twenty-four hours. 

Therapeutics. —With our present knowledge of the physiological 
action of veratrum viride, it is evident that there are only two rational 
indications for its use,—namely, to reduce spinal action and to reduce 
arterial action. Owing to the very great effect veratrum viride has 
upon the circulation, and to the numerous drugs which are purer spinal 
depressants, it is never called for to meet the first indication, and in 
practice should simply be used to lessen the force of the circulation. 
The use of the drug in typhoid fever and other adynamic diseases is 
simply an irrational and dangerous practice, founded upon an erro¬ 
neous idea of the action of the remedy. 

Yeratrum viride has been recommended in mania a potu; and in 
cases of irritation of the brain from drink, with strong bounding pulse, 
it may be of great service ; but in the true delirium tremens , with uni¬ 
versal adynamia, it is a thoroughly improper remedy, capable of deep- 


* Professor S. R. Percy states that a dilatation of the blood-vessels of the frog’s web and 
bat’s wing can be readily seen by the microscope to follow the administration of the drug. 



CARDIAC DEPRESSANTS. 397 

ening the prostration into fatal exhaustion: indeed, I have known of 
death occurring in this disease from its use. 

When true sthenic arterial excitement is to be combated in any 
disease, except it be gastritis, veratrum viride may be employed as a 
prompt, thoroughly efficient, and at the same time very safe remedy,— 
very safe, since it is almost incapable of producing death in the robust 
adult, unless used with great recklessness and in repeated doses. In 
the early stages of sthenic pneumonia it offers, I believe, the best known 
method of reducing the pulse-rate and the temperature, and of ameli¬ 
orating the disease.* It is hardly necessary to mention other individual 
diseases in which veratrum viride may be employed to carry out the 
present indication. 

In peritonitis its tendency to cause vomiting is very much against its 
use, and, unless this action can be controlled, should interdict its em¬ 
ployment. I desire, however, to call attention to its value in prevent¬ 
ing inflammation after severe abdominal injuries, —indeed, after any 
severe injury. Thus, I am cognizant of the case of a woman whose 
belly was torn open by the horn of a bull; the abdominal walls were 
rent for about six inches, and the sigmoid flexure of the colon came 
out and was dragged in the dirt. It was washed, replaced, the wound 
sewed up, the patient restricted to low diet, and veratrum viride admin¬ 
istered very carefully so as to keep the pulse as depressed as possible 
and at the same time to avoid vomiting, to aid in which opium was also 
given. Recovery without a bad symptom resulted.f 

As an emetic, veratrum viride should never be employed. 

In chronic cardiac diseases it may be used in precisely those cases in 
which digitalis is contra-indicated,— i.e., where there is excessive hyper¬ 
trophy. 

The contra-indications to the use of veratrum viride are cardiac 
weakness and the existence of general adynamia. 

Toxicology.— Although veratrum viride is a remedy of great power, 
capable of producing the most alarming symptoms, yet I believe it to 
be the safest of all the cardiac depressants; certainly it is far less dan¬ 
gerous than aconite. Overdoses of it provoke vomiting so soon and so 
certainly that it is somewhat doubtful whether a robust adult could be 
killed by a single dose of any of its officinal preparations, especially if 
prompt and judicious treatment were afforded. I have several times 
known a teaspoonful of its fluid extract to be taken; and Professor 
Percy cites recoveries after the ingestion of a tumblerful of the tinc¬ 
ture ; after thirty grains of the resinoid; after two doses—a tumblerful 
each—of a syrup representing a pound of the root to the pint. A feeble 
child, eighteen months old, was killed by thirty-five drops of the tincture 


* Compare Oulmont, Bulletin de Thirapeutique, t. lxxiv. p. 146, and MM. Zuber and 
H. Hirtz, Ibid., t. lxxvi. p. 468. 

•j- Consult also Dr. C. S. Bishop, American Journal of the Medical Sciences, Oct. 
1861. 



398 


GENERAL REMEDIES. 


(. Amer. Journ. Pharm., 1865), and a doubtful case of fatal poisoning in 
the adult is mentioned in Med. and Surg. Rep., xl. 372. 

I have seen the most alarming symptoms result from large medici¬ 
nal doses repeated at short intervals, and have been astonished at the 
rapidity with which they yielded to treatment; but Dr. J. D. Blake re¬ 
ports (. American Med. Weekly, No. 20, 1874) a death resulting from the 
administration of between three and four drops of Norwood’s tincture 
every two hours to a babe eleven months old; and a man, convalescing 
from typhoid fever, was killed by a drachm of the fluid extract ( Phila. 
Med. Times, xiv. 863). 

In cases of poisoning, vomiting should be encouraged by large 
draughts of warm water until the stomach is well washed out. Then 
the patient should be forced to lie flat upon the back, with the head 
lower than the feet, and the efforts at vomiting should be restrained. 
If they cannot be checked, and if the prostration be severe, on no 
account should the patient be allowed to rise up, but must be made to 
vomit into a towel. A full dose of laudanum should be given by the 
rectum, and brandy or whisky be administered by the mouth. I have 
noticed that spirits will sometimes be retained only when given undi¬ 
luted, and in such form will quiet the stomach at once. If the stomach 
refuses alcohol in any shape, the rectum should be made use of. Am¬ 
monia may be employed as an adjuvant to alcohol, and in extreme cases 
should be injected hypodermically, or even into a vein. The use of 
external heat is important, and mild flagellations, rubbing with coarse 
towels, sinapisms, etc., may be used to keep up the external capillary 
circulation. 

Administration. —In administering veratrum viride, it should al¬ 
ways be borne in mind that it will do no good in acute disease unless 
given in increasing doses until its physiological action is manifested. 
In almost all cases vomiting is to be avoided as far as possible. To do 
this, small quantities of the drug should be given at short intervals, 
and corresponding doses of laudanum (five to ten drops) should be ex¬ 
hibited fifteen minutes before each dose of the veratrum viride. An 
hour is generally the best interval between the doses. The drug should 
always be administered in the form of the fluid extract ( Extractum Vera- 
tri Viridis Fluidum , U.S.), dose, one to three drops; or of the tincture 
(Tinctura Veratri Viridis, —1 to 2, U.S.), dose, three to six drops. A 
saturated tincture is sometimes kept in the shops under the name of 
Norwood's tincture. 

Veratrum Album. —In cases of human poisoning with veratrum 
album the symptoms* have been—excessive vomiting, generally ac¬ 
companied by severe abdominal, and often oesophageal, pain, and fol¬ 
lowed by a very severe diarrhoea; intense prostration and muscular 


* For cases and analysis of symptoms, see New York Med. Record, p. 121, 1872. 



CARDIAC DEPRESSANTS. 


39J> 


relaxation; very; pronounced reduction of the temperature and pulse, 
the latter being sometimes rapid and almost imperceptible in the ad¬ 
vanced stages, and finally becoming extinct; sunken eyes, contracted, 
anxious countenance, a cold skin clammy with profuse perspiration, 
and other evidences of collapse. The mind remains clear until the 
last. A fatal result is very common, and, when recovery occurs, the 
convalescence is usually protracted. 

The exact nature of the active principles of veratrum album is still 
involved in doubt. Pelletier and Caventou thought that they found 
supergallate of veratrine in it. So far as I can make out from the au¬ 
thorities at my command, Simon* claims that there are three alkaloids 
in veratrum album,— veratrine , barytine , and jervine; and Dr. Mossel 
(Sur la Veratrine , These, Paris, 1868) certainly indicates that sabadilline 
and barytine are the same. The subject has been elaborately inves¬ 
tigated by Dr. Chas. L. Mitchell, who has found two alkaloids in the 
rhizome, one of which he denominates jervine, the other veratralbine. 
The resin, when entirely freed from alkaloids, is inert. In a number 
of experiments made separately by Mr. Mitchell, Dr. J. R. Haynes, 
and myself, the veratralbine proved itself a most active poison, one- 
tenth of a grain killing a large pigeon in four minutes, and one-twen¬ 
tieth of a grain a dog of fourteen pounds’ weight in one hour. The 
symptoms were nausea and vomiting, with violent purging, if the ani¬ 
mal lived some time, salivation, muscular weakness passing into pa¬ 
ralysis, convulsions, and death,—from failure of respiration after mod¬ 
erate toxic doses, from cardiac arrest after very large ones. When the 
fatal result had been slowly produced, intense hyperasmia of the intes¬ 
tinal mucous membrane was found after death. Veratralbine appears to 
be very closely allied both in chemical and in physiological properties 
to veratrine. 

VERATRINA. U.S. 

This alkaloid is procured from the seeds of Veratrum Sabadilla 
(Asagraea officinalis f). As found in commerce, it is almost always more 
or less impure, and occurs as a grayish-white powder of an intensely 
acrid taste, and producing, even in the minutest quantity, when smelled, 
frequently-repeated sneezing, which may continue for hours. It has 
when pure been considered uncrystallizable, but Merck has obtained it 
in rhombic prisms about half an inch in length, through the spontaneous 
evaporation of its alcoholic solution. It is very slightly soluble in boil¬ 
ing water, not at all in cold water; soluble in alcohol, freely so in ether, 
and still more so in dilute acids. 

Veratrine dissolves in concentrated sulphuric acid, with the produc¬ 
tion of a yellow color, changing in five minutes into orange, then into 

* I have not had access to Simon’s original papers. 

f The action of sabadilline, the congeneric alkaloid of veratrine, has been partially 
studied by Dr. I. Urpav (Montpellier Med., 1883, i. 274), who finds it to have only about one- 
twelfth the toxic power of veratrine. 



400 


GENERAL REMEDIES. 


blood-red, and in half an hour into a splendid carmine. Masing states 
that this test is very faint with 0.0026 of a grain. If some bromine 
be dropped into the freshly-prepared sulphuric acid solution, a beautiful 
purple results. A more delicate test than either of those yet noted is, 
according to Masing, that of Trapp, which consists in warming the 
colorless solution of veratrine in concentrated hydrochloric acid, when a 
dark-red very persistent color is produced. This test is said to afford 
very marked proof of the presence of 0.0026 of a grain of the alkaloid, 
and to be especially useful when the veratrine is impure. 

Physiological Action.— Veratrine is exceedingly irritating to any 
surface it may come in contact with, producing when given hypodermi¬ 
cally or endermically severe pain, and when rubbed on the skin a feel¬ 
ing of warmth, followed by prickling, severe pain, numbness, and, if its 
use be persisted in, a marked redness. On the mucous membranes its 
action is even more decided. In the nostrils the minutest portion of it 
produces intense irritation, as shown by repeated sneezing and free dis¬ 
charge, which may be bloody. Upon the tongue a speck causes burn¬ 
ing, with free salivation. 

When taken internally, in small doses, it produces slowing and 
weakening of the pulse; more freely administered, indications of gastro¬ 
intestinal irritation; and in large doses it is followed by violent vomit¬ 
ing, serous purging, often with intense burning in the mouth and 
throat, and general muscular weakness. No fatal case of poisoning is 
on record ;* but in the experiments of Esche on himself a half-grain of 
the acetate produced collapse, with a pale, cold, wet skin, pinched feat¬ 
ures, a rapid, thready, irregular pulse, violent vomiting, and marked 
muscular tremblings. Other observers have noted more pronounced 
indications of convulsions; and, according to Bardsley, when absorbed 
through the skin, instead of purging it produces in some cases very 
free diuresis. On the whole, the resemblance between the symptoms 
as induced in man and in the lower animals is, so far as we know, 
complete. 

The phenomena of veratrine-poisoning in a mammal are violent 
muscular twitchings and convulsions, which are often plainly excited by 
external irritants, severe vomiting, generally but not always accom¬ 
panied by purging, and disturbance of motion, respiration, and circula¬ 
tion. The pulse is at first, if the dose be not too large, quickened and 
strengthened, but in a very short time it becomes slower and weaker, 
and finally very frequent, thready, and irregular. There is early a 
marked loss of muscular power, even in the midst of the convulsions, 
and the latter may give way to the quiet of paralysis, or may continue 
up to death. 

According to the researches of Claus (Journal of Anatomy , viii.), 

* In St. George’s Hospital Reports, 1870, vol. v., Dr. C. Paget Blake reports a case of 
recovery after the ingestion of a liniment supposed to contain three grains of veratrine ! In¬ 
tense itching of the skin was a prominent symptom. 



CARDIAC DEPRESSANTS. 


401 


veratrine in toxic doses causes first a slight fall of temperature, then 
a rise to about normal, and finally a fall immediately before death. 
Sabadilline, on the contrary, produces a rise of temperature, followed 
only by a partial fall, so that the bodily heat even at the moment of 
death is above normal. 

M. Prevost (Robin’s Journal de VAnatomie , 1868, t. v. p. 206) has, 1 
think, very well divided the action of veratrine in poisonous doses into 
three stages: first, that of excitation or restlessness; second, that of 
convulsions; third, that of paralysis. It should, however, be under¬ 
stood that these may after large doses be fused into one. I have seen 
an animal suffer a convulsion, or perhaps merely give a convulsive 
shudder, and drop dead. 

After death from a very large dose, the muscles are found to have 
lost more or less completely their irritability, so that they either do 
not respond, or respond very feebly, to the strongest faradic currents. 
That this is due to a direct influence of the alkaloid upon them is 
proved by the fact, first noted by Kolliker ( Virchow's Archiv, Bd. x. p. 
257), but which I in common with other observers have experimentally 
confirmed, that if an artery be tied before poisoning, all the muscles 
supplied by that artery maintain their integrity. 

It is evident that veratrine is a muscle-poison; but it has other 
powers, and the subject is best studied in detail, system by system. 

Central Nervous System. —Upon the cerebrum the action of veratrine 
is not very marked. That the convulsions are not cerebral is shown by 
the fact, which I have frequently noted, that they are in no wise af¬ 
fected by division of the spinal cord. The spasms must be, therefore, 
either peripheral or spinal in origin. M. Prevost (Robin’s Journal de 
VAnatomie, 1868, p. 209) has found that convulsions will occur in the 
frog even when the spinal cord is destroyed, but that under these cir¬ 
cumstances the convulsions are not spontaneous, but occur only when an 
irritation is applied to a part, and are limited to the part irritated. A 
fact analogous to this was noticed by Kolliker ( Virchow's Archiv , Bd. x. 
p. 262, Exp. IX.): in frogs whose nerves were paralyzed by curare, 
the exhibition of veratrine induced phenomena similar to those just 
noted. These facts, however, do not prove that the convulsions in the 
veratrized frog are not spinal, but only show that there is a state of 
excitation of the muscles. But M. Prevost furnishes the following 
direct proof that the cord in veratrine-poisoning is not affected. The 
hind legs of a frog were separated from the rest of the body by a very 
tight ligature, so placed as not to include the lumbar nerves. Some 
veratrine was then introduced into one of the fore legs, and of course 
found its way into the spinal cord and the anterior portions of the 
body. Under these circumstances it is evident that the convulsions 
produced, if spinal, would affect the whole body, but if peripheral 
would be confined to the anterior part of the frog. It was found that 
the posterior legs were never affected; that while irritation of them 

26 


402 


GENERAL REMEDIES. 


caused most violent spasms in the anterior part of the body, only 
the normal reflex actions occurred in those muscles which were not 
reached by the poison. If this experiment be confirmed (and I see no 
intrinsic reason to doubt its accuracy), to Prevost belongs the credit 
of having proved that veratrine has no action on the motor centres of 
the spinal cord. 

There is, however, an apparent opposition between the experiments 
of Prevost and those of Kolliker ( Virchow's Archiv , Bd. x. p. 261). 
The latter observer noted (Exp. YI.) that when the skull of the frog 
was opened and a ten-per-cent, alcoholic solution of veratrine dropped 
on the cord, violent general tetanic convulsions were induced; also 
(Exp. IY.) that when one crural artery and vein of a frog were tied 
and the veratrine solution placed in the mouth, tetanus ensued, in¬ 
volving the protected limb, and continuing there after it had ceased in 
the other members. I see no way of reconciling these experiments of 
Kdlliker with those of Prevost except by supposing either that the 
latter are incorrectly observed, or, what seems much more probable, 
that the poison in the former reached the protected parts by diffusion, 
although in less quantity than it did the other members: this would 
also explain the continuance of tetanus in the protected limb after it 
had ceased elsewhere. 

M. Guttmann (. Reichert's Archiv, 1866) is in accord with Kolliker 
in his experiments, for he states that, notwithstanding the artery of a 
limb is tied, yet spasms occur in the leg during the convulsive stage of 
veratrine-poisoning: of course the “ diffusion” theory would apply to 
this as well as to the experiments of Kolliker. 

The only conclusion to be drawn from the evidence seems to me to 
be that at present it is uncertain whether veratrine does or does not act 
upon the motor centres of the cord. 

In regard to the action of the drug upon the sensitive centres of the 
cord, our knowledge is by no means perfect. Anaesthesia of the pos¬ 
terior feet was noticed in the frogs experimented upon by Prevost in 
the manner described; but when the circulation is cut off from the 
feet of a frog, loss of sensibility always ensues. 

Peripheral Nervous System. —The study of the action of veratrine 
upon the peripheral motor apparatus evidently divides itself into a 
study of the influence upon the muscles and the extreme nerve-endings 
in them, and upon the nerve-trunks. 

There can be no doubt that veratrine finally destroys the contractile 
power of the muscle itself, so that it fails to respond to any irritation 
whatever, and soon, becoming stiff, exhibits the acid reaction of post¬ 
mortem rigidity. Thus far all recent observers are in accord; and I 
have frequently witnessed the same phenomenon. Kolliker in some of 
his experiments (loc. cit .) notes that the muscle in the early stage of 
veratrine-poisoning responded inordinately to stimuli. The study of 
this phenomenon has been especially made by Bezold and Hirt ( Unter - 


CARDIAC DEPRESSANTS. 


403 


such. Physiolog. Laborat. Wurzburg, i.), by M. Prevost,* by Kossbach 
(Pfluger's Archiv, xiii. 617), by Marey and Maurice Mendelssohn (Tra- 
vaux du Laborat. de M. Marey , xiv., and Comptes-Rendus Soc. Biolog., 
1883, 147). W ben a muscle during the convulsive stage of veratrine- 
poisoning is momentarily stimulated, instead of the usual momentary 
contraction a prolonged tetanic spasm results and lasts some seconds : 
this spasm is induced by the slightest irritation. When a nerve is 
irritated repeatedly within a short time, the tributary muscle loses its 
power of entering upon a “ veratrine contraction,” but if left quiet for 
a time recovers itself. There is therefore in veratrine-poisoning, pre¬ 
ceding the stage of muscular paralysis, a stage of muscular hyper¬ 
excitability. To this are due no doubt in great part, if not altogether, 
the convulsions. It can scarcely be doubted that it is the result of an 
action not upon the nerve-endings, but upon the sarcolemma of the 
muscle.f That the muscular paralysis is of similar nature would seem 
to be proved by the rapid changes which take place in the muscle 
after death, and by the fact, noted by Guttmann ( Reichert's Archiv fur 
Anatomie , 1866, p. 498), that while frogs apparently dead from nerve- 
poisons such as atropine, strychnine, and curare often recover them¬ 
selves after a period of stupor, those poisoned with veratrine never do. 

When a muscle is dead, galvanization of the nerve of course elicits 
no response; but it is possible that a substance may be at the same 
time a nerve-poison and a muscle-poison. Yeratrine is both a muscle- 
poison and a nerve-poison. Kolliker denies this, but the experimental 
evidence brought forward by him amounts to almost nothing. Gutt¬ 
mann ( loc. cit .) asserts that in his experiments, whenever irritation of 
a nerve failed to elicit a response, direct irritation of the muscle was al¬ 
ways equally unavailing. Bezold and Hirt (loc. cit.) experimented, with 
a full knowledge of Guttmann’s work, with small and with large doses, 
and evidently with great care. They found (loc. cit., p. 90) that when 
a small dose is used there is at first a very marked increase in the irri¬ 
tability both of the nerve and of the muscle, so that, whether the cur¬ 
rent be applied directly to the muscle or indirectly through the nerve, 
contractions take place more readily than normal. After a time, both 
muscle and nerve lose their irritability, so that no contraction follows 
either the direct or the indirect stimulation. The process does not go 
on pari passu in the two organs. The irritability increases sooner and 
is sooner lost in the nerve than in the muscle, so that there is a time 
when galvanic irritation of the nerve fails to induce contraction, al- 


* Quoted by Husemann. 

f Fick and Boehm, in the elaborate paper already referred to, believe that they prove that 
the prolongation of the muscular contractions in veratrine-poisoning is due to a greater in¬ 
tensity of the chemical processes of the muscles, and not to a delay of the process of restitu¬ 
tion. A discussion of this point would involve that of muscular physiology, and cannot be 
entered into here. The weak point of the argument made by Fick and Boehm may, however, 
be pointed out. Granting all their asserted facts, it is perfectly possible that greater intensity 
of the chemical processes is an effect, not a cause, of the prolonged contractions. 



404 


GENERAL REMEDIES. 


though the muscle still retains its functional power and reacts instantly 
to direct stimulation. Moreover, the upper or spinal end of the nerve 
dies first, so that at a certain stage irritation of the nerve-trunk close 
to its origin fails to induce contraction of the tributary muscle, al¬ 
though when applied lower down it elicits a response. This important 
observation is confirmed by Fick and Boehm ( Arbeiten Physiolog. Labo- 
rat. der Wurzburger Hochschule, 1873, p. 147), and by I. Ott {Toxico¬ 
logical Studies , Philada., 1874), and would seem to prove that veratrine 
acts directly on the nerve-trunks. Fick, however, affirms that under 
these circumstances he has frequently proved the existence of the nor¬ 
mal muscular galvanic currents in the seemingly dead nerve-trunks, 
and that therefore it is only the peripheral nerve-endings which are 
attacked by veratrine. But it is difficult to reconcile this observation 
of Fick with some of those of Bezold and Hirt. At present, therefore, 
it must be considered undetermined whether it is the nerve-endings 
solely, or the whole peripheral nerves, which are affected by veratrine. 

As already stated, the action of veratrine upon the sensory centres 
is doubtful; its influence upon the peripheral sensitive nerves has not, 
that I am aware of, been carefully worked out, but the effects of its 
local application to the human skin seemingly show that it first strongly 
excites and then paralyzes them. 

Circulation. —After death from a large dose of veratrine, the heart 
is soft, dilated, full of blood, and incapable of responding to galvanism; 
i.e., the heart-muscle is dead. According to Bezold and Hirt (loc. cit.), 
after a small dose there are quickening of the pulse and rise of the 
blood-pressure, which soon return to the normal condition; while im¬ 
mediate and persistent fall in the number of the heart-beats and in the 
arterial pressure follows a large dose. If the vagi be divided previous 
to the poisoning, a large dose produces a temporary increase in the 
pulse; and a stimulation of the distal end of the cut nerves by a cur¬ 
rent too slight to be felt in the unpoisoned animal retards very markedly 
the beat. From these facts it follows that in the uninjured animal, 
after poisoning by veratrine, there is an inhibitory retardation of the 
pulse, and also an excitation of the peripheral ends of the vagi. That 
it is not merely the peripheral inhibitory apparatus which is affected 
was proved by injecting the alkaloid into the carotid,— i.e., into the 
inhibitory centre,—when there happened an instantaneous and remark¬ 
able retardation of the heart-beat, which could only have been caused 
by excitation of the inhibitory centre. In a later stage of the poison¬ 
ing the strongest faradic currents applied to the pneumogastrics fail to 
affect the heart. It is, therefore, evident that veratrine first exalts and 
then destroys the functional activity of the par vagum, in a manner parallel 
to its action on the spinal nerves. 

When the heart is separated from the nerve-centres by section of 
the par vagum and of the spinal cord, veratrine produces, according 
to Bezold and Hirt, at first increase in the pulse and blood-pressure, 


CARDIAC DEPRESSANTS. 


405 


secondly, lowering of both to the minimum; showing that it exerts 
upon the internal heart-ganglia, or upon the heart-muscle, its peculiar 
action of first stimulating and afterwards paralyzing functional activity. 
This is in accord with the results obtained by S. Ringer, who finds that 
veratrine acts directly upon the cardiac muscle as it does upon the skele¬ 
tal muscles. Each excitation causes in the veratrized frog’s heart a pro¬ 
longed series of incoordinated contractions; therefore a lessened regula¬ 
tion with an increased amount of force-generation (Arch. Med., 1882, p. 21). 

That the poison has a similar action upon the vaso-motor centres 
seems probable from the facts noted by Bezold and Hirt: first, that 
injection into the carotid after section of the pneumogastrics causes 
immediate rise of the blood-pressure; second, if the mesenteric arteries 
have been previously bared, they can be seen to contract. This excita¬ 
tion is followed after a time by vaso-motor paralysis and dilatation of 
the vessels. 

Respiration. —Bezold and Hirt conclude, from the fact that after 
section of the pneumogastrics even the smallest doses of veratrine 
cause retardation of the respiration without previous increase, that the 
alkaloid depresses and finally paralyzes the respiratory centre. 

Therapeutic Action. —The study of the physiological action of 
veratrine shows that its rational therapeutic use must be limited. As 
a heart-depressant, it is much inferior to aconite and veratrum viride, for 
obvious reasons, and, although it has been used as such, it has not 
achieved much reputation. When exhibited in full doses it is very apt 
to give rise to exceedingly disagreeable secondaiy symptoms, and has 
no advantage over the medicines just named. Some years ago it was 
employed in acute rheumatism , having been recommended by Turnbull, 
Bardsley, Piedagnel, Trousseau, and others; but it is not so efficacious 
in this disease as other far less dangerous remedies by which it has 
been superseded. The same is true of its employment in dropsy; and 
I know of no condition which would justify its internal use. 

Bardsley originally used it in neuralgia , especially when arising 
from cold. He used it both internally and externally. At present it is 
rarely employed except as a local application. My own success with it 
has not been very encouraging, but others of larger experience recom¬ 
mend that it be rubbed over the affected nerves in rheumatic neuralgia. 

As an external stimulant and rubefacient it is sometimes used with 
good effect in narcotic poisoning; also in various spinal troubles as an 
irritant applied to the spine, and to the skin of the paralyzed limbs, to 
aid in maintaining circulation; but all these indications can, I think, be 
better met by other means. In regard to the dose of veratrine for 
internal use, it should be borne in mind that one-sixteenth of a grain 
has produced the most alarming symptoms (Taylor, Medical Jurispru¬ 
dence, 2d edition, London, 1873). 

An ointment ( Unguentum Veratrince —1 to 26.5, U.S.) and an oleate 
(Oleatum Veratrince —1 to 50, U.S.) are officinal. 


406 


GENERAL REMEDIES. 


ARNICAE FLORES—ARNICA FLOWERS. U.S. 

ARNICA RADIX—ARNICA ROOT. U.S* 

The flowers of the Arnica montana, a perennial composite, native 
of Northern Europe and Asia, and said also to he found in the North¬ 
western United States. The yellow flowers have about fourteen striated 
ligulate tridendate florets in the ray, twice as long as the disk, which 
consists of numerous tubular florets. The taste is bitterish and acrid. 
The rhizome is also employed medicinally, but is not recognized by the 
U.S. Pharmacopoeia. Two alkaloids, cytisine and arnicine, are stated 
to have been found in the flowers. The first of these is believed to be 
identical with the alkaloid of the seeds of the laburnum-tree ( Cytisus 
Laburnum). 

Physiological Action. —Locally, arnica is stimulating, and, if in 
sufficient strength, decidedly irritating. Upon some skins the tincture 
acts even violently, rapidly developing an acute eczematous inflamma¬ 
tion of the upper dermal layers, as manifested by hypersemia, papules, 
vesicles, excoriations, crusts, and scales in regular sequence ( Boston Med. 
and Surg. Journ., Jan. 1875 ; also Ann. de Dermat. et de Syph., 1886, vii.) 

That the influence which the drug exerts upon the general system 
when taken internally is very decided is certain, but the exact nature 
of this influence is at present unknown. The only positive knowledge 
that we have in regard to the physiological action of arnica is that 
derived from experiments made by Dr. H. A. Hare ( Bost. Med. and 
Surg. Journ., Jan. 12, 1888) in the laboratory of the University of 
Pennsylvania. He finds that the fluid extract in doses of five to ten 
drops produces in the dog a slowing of the cardiac beats, with increase 
of the fulness of the pulse-wave and a very slight increase of the arte¬ 
rial jiressure, the slowing of the pulse being the result of a stimulation 
of the pneumogastric nerves, and the slight increase of the arterial 
pressure probably caused by increased heart-work. After large doses 
the pulse becomes very rapid, from pneumogastric paralysis, the arterial 
pressure remaining near the norm. Yiborg (quoted by Stille) affirms 
that in horses and cows it causes increased action of the heart, flow of 
urine, and warmth of skin, followed by very decided general depression. 
According to Stille, the effects of moderate doses on man are similar to 
those noted as occurring in the lower animals,—namely, increase of the 
cardiac action, of the respiration, of the temperature of the skin, and 
of the perspiration and urine, along with very decided symptoms of 
gastric irritation. On the other hand, it is asserted that ten drops of 
the tincture every three or four hours act as a decided arterial depressant 
(Dr. C. C. Balding, Lancet, Dec. 1870). The symptoms of poisoning 
seem strangely to vary. Thus, in a woman, two cups of a strong in- 

* I have allowed this drug to stand in the class in which it was put in former editions, 
although what little knowledge we have of its physiological action seems to indicate that it is 
not a cardiac depressant, its most marked effects being those of a local irritant. 



CARDIAC DEPRESSANTS. 


407 


fusion produced violent gastrointestinal irritation, as shown by vomit¬ 
ing and choleraic diarrhoea, reduction of the pulse to 60, and finally 
collapse (Bull. Therap., lxxvi.). In Barbier’s case (quoted by Stille), 
an infusion of eighty grains of the flowers caused giddiness and intense 
muscular weakness, with spasmodic movements of the limbs. In 
another, not fatal, case ( Lancet , Nov. 1864), according to the state¬ 
ment of the patient, an ounce of the tincture did not produce any 
symptoms for eight hours, when approaching collapse, dilated, im¬ 
movable pupils, with a cold, dry skin, and a feeble fluttering pulse, rap¬ 
idly supervened upon an intense epigastric pain, which was increased 
by pressure. 

In a not fatal case reported by Dr. W. A. Thorn ( Virginia Medical 
Monthly , Sept. 1883), four hours after ingestion of a fluidounce of a 
tincture by a young man, the pulse was 100, full and strong, the tem¬ 
perature normal, insensibility complete, conjunctiva anaesthetic, respi¬ 
rations 18 per minute, no vomiting or purging. Twelve hours later the 
patient became wildly delirious; the next day he suffered from burning 
pain in the abdomen, diarrhoea, and free diuresis. 

Therapeutics.— In the present state of our knowledge, the internal 
use of arnica is experimental. Externally it is employed as a stimu¬ 
lant application in bruises and sprains, generally in the form of tincture 
( Tinctura Arnicce Florurn —1 to 5, U.S.; Tinctura Arnicce Badicis —1 to 
10, U.S.), which may be applied pure, but sometimes as fomentations 
of the flowers. Its property of occasionally producing intense dermal 
irritation should be borne in mind. An extract ( Extractum Arnicce 
Badicis, U.S.) and a fluid extract (. Extractum Arnicce Badicis Fluidum, 
U.S.) are officinal. 

ACONITUM. U.S. 

The Aconitum Napellus,* or monkshood, is a tall perennial, indige¬ 
nous in Europe, and cultivated in this country for the sake of its spike 
of blue flowers. The leaves are three or four inches in diameter, and 
cut almost to the base into three to seven three-lobed, wedge-shaped 
divisions. 

The root, which is the only officinal portion, is from three to four 
inches long, very tapering, about three-quarters of an inch in diameter 
at the base. Its taste is bitterish, acrid, and after a little while benumb¬ 
ing, giving origin to intense tingling of the lips and mouth. It is to 
be distinguished from horseradish root, with which it has been some¬ 
times fatally confounded, by its external brown color and its lack of 

* All the species of the genus Aconitum are more or less poisonous, although A. 
Napellus is the only one officinal. For a study of the comparative strength of the various 
aconites, see Schroff, Journal fur Pharmacodynamik, 1857, p. 335. He arranges them as 
follows, commencing with the most virulent: A. ferox, A. Napellus, with its varieties, neomon- 
tanum, tauricum, and variabile , A. Cammarum, A. paniculatum , A. Anthora. The toxic 
properties of A. Anthora were very weak. Lycoctonine is the alkaloid of A. lycoctonum. 
For a physiological study of it by Dr. Ott, see Phila. Med. Times, vi. 25. 



408 


GENERAL REMEDIES. 


odor when scraped. The whole plant is active and tastes like the 
root. 

In 1833 Geiger and Hesse discovered in aconite an alkaloid, Aconitine, 
which is undoubtedly the active principle of the drug. In commerce there 
are several varieties of it, made by different large manufacturers: the 
German aconitine , which is very impure, and, according to Husemann, 
is less active than the extract; impure English aconitine; and the so- 
called English aconitine , prepared by Morson and said to be chemically 
pure. The latter is a grayish powder.* 

Duquesnel ( Comptes-Rendus , vol. lxxiii., 1864) first obtained the 
aconitine in the form of colorless, rhombic, tabular crystals, soluble in 
alcohol, benzin, and ether, extremely soluble in chloroform, very slightly 
soluble in water, insoluble in glycerin. 

The salts of aconitine are soluble, and from their solution the alkaloid 
is precipitated by alkalies in an amorphous state. That aconitine is the 
only active principle of the root would seem to follow from the experi¬ 
ments of Hottot ( Journal de Physiologie , 1864). 

Physiological Action. —When applied to a raw surface, or to the 
skin, aconite, or its alkaloid aconitine, acts as a local irritant and nar¬ 
cotic, soon producing numbness, with tingling, which may persist for a 
long time. When given in sufficient dose internally, it is a violent 
poison, acting, so far as is known, similarly upon all animals. 

If the dose be large, death may be almost immediate, and, if the 
alkaloid be given hypodermically, may occur in less than a minute. In 
such cases the result is apparently due to sudden paralysis of the heart- 
muscle. 

After moderate toxic doses, the prominent symptoms are great dis¬ 
turbance of the respiration, muscular weakness, vascular depression, 
and finally death, with or without convulsions. As I have seen the 
rabbit after the injection of one-sixth or one-quarter grain of Morson’s 
pure aconitine, the animal commences to jump vertically in a very 
peculiar manner, and often to squeal piteously. The jumping soon 
grows less and less powerful, and finally is replaced by severe convul- 


® In 1857, Hiibschmann announced the presence in minute quantity of a second alkaloid 
in the root of Aconitum Napellus,— Napelline. Schroff® (Journal fur Pharma codynamik, i. 
3) could find no essential difference between its action and that of German aconitine. T. and 
H. Smith, of Edinburgh, have found a third, non-poisonous alkaloid, Aconelline, which they 
think to be probably identical with narcotine; and Fliickiger asserts that there are four alka¬ 
loids contained in the genus Aconitum, —namely, Aconitine, Pseudaconitine ,f Napelline, and 
Lyctonine (Sydenham Soc. Year-Book, 1869 and 1870). Recently Dr. C. A. Wright has found 
that there are three alkaloids in Aconitum Napellus,—crystallizable aconitine, a nearly inert 
base, picra aconitine, and a third alkaloid, incapable of crystallizing or of forming crystallizable 
salt, which is said to form frequently the bulk of commercial aconitine. 

* From what Schroff says about the material he used in his experiments, it is evident that he had no 
proof that it was genuine napelline. 

f Boehm and Ewens have physiologically studied the alkaloid of Aconitum ferox, under the name of 
p»eudaconitine, and found the difference between its action and that of aconitine to be one of degree, not 
of kind: it was the stronger of the two (Archiv fur Exper. Path, und Pharm., Bd. i., 1873). 




CARDIAC DEPRESSANTS. 


409 


sions, during which the animal often lies prostrate on its side. In the 
dog, however, the muscles have remained without a quiver during all 
stages of the poisoning; in the horse Harley has noticed convulsions 
(St. Thomas's Hospital Reports, v.). The convulsions are an inconstant 
symptom, dependent upon peculiarities of the individual or species, 
as well as upon the amount injected. Dilatation of the pupil frequently 
occurs, if it be not, indeed, a constant phenomenon. There is often 
severe vomiting. 

The symptoms which are induced by small therapeutic doses of 
aconite in man are reduction of the force and frequency of the circula¬ 
tion, a sense of muscular inertia and weakness, and a slight tingling in 
the extremities or in the lips. If the dose administered be large, all 
these symptoms are intensified; the muscular weakness is extreme; 
the tingling is felt all over the body; the pulse is feeble, and reduced to 
thirty or forty per minute; the respirations are diminished; giddiness 
and disordered vision may be manifested, especially when the erect 
posture is assumed. After three or four hours these symptoms gradu¬ 
ally subside. 

When a poisonous dose has been ingested, the first thing noticed in 
most cases is a burning or tingling in the throat or in the extremities, 
soon spreading over the whole body. The pulse rapidly falls in fre¬ 
quency, and in a very little time becomes exceedingly weak, intermit¬ 
tent, irregular, and finally imperceptible; the muscular strength is 
greatly reduced, and sometimes almost entirely gone; the respirations 
are shallow, feeble, irregular, and infrequent; the general sensibility 
is very much benumbed, so that marked anaesthesia of the surface is 
present; the skin is bedewed with a cold sweat; the countenance is 
anxious, sunken, livid, and the eyes are often protruded, or are even 
spoken of as glaring; the pupil is generally dilated, but when there are 
no convulsions may be contracted; gastric burning is sometimes com¬ 
plained of, and severe vomiting may be present, but the stomach is not 
rarely retentive. The intellect generally remains unaffected until very 
near the close, sometimes to the very moment of death.* In the col¬ 
lapse of the latter stages of aconite-poisoning the special senses may be 
lost, especially the sight. The voice is very generally extinguished. 
Convulsions occur in some cases, not in others; and certainly in some 
instances, if not always, the patient is unconscious during their con¬ 
tinuance. Diplopia, or other disorder of vision, has been noted in some 
cases. Death may occur suddenly, especially directly after some exertion 
on the part of the patient, from syncope. 

The symptoms which aconite produces in man and in the lower 
animals are so entirely identical that the conclusions arrived at in re¬ 
gard to the latter may be accepted without reserve as applicable to the 
former. 


* Pereira, however, states that in some recorded cases stupor has occurred. 



410 


GENERAL REMEDIES. 


Circulation. —The action of aconite upon the circulation is very 
decided. According to Dr. Achscharumow ( Reichert's Archiv , 1866, p. 
255), in the frog a moderate toxic dose of aconitine produces at first a 
reduction in the number of the heart’s pulsations, then an increase in 
the rapidity of its action, with very evident loss of power, and finally 
irregular systolic movements, with very long intervening pauses ending 
in diastolic arrest. Dr. Rudolf Boehm and L. Wartmann ( Arbeiten 
Physiolog. der Wurzburger Hochschule, 1873) have substantially con¬ 
firmed these observations. 

In the higher animals the exhibition of aconite in sufficient doses 
yields similar results. In the dog and cat (Boehm and Wartmann, and 
my own experiments) there is a steady sinking of the arterial pressure. 
In the rabbit, according to Boehm and Wartmann, the fall of pressure 
is preceded by a brief rise; this rise has also been noticed in the dog by 
Laborde and Duquesnel (Des Aconits , p. 130). The rate of the heart’s 
pulsation also undergoes reduction, and there is finally diastolic arrest 
in dogs as in other mammals. 

The method by which the aconite influences the heart is not cer¬ 
tainly settled. According to the experiments both of Boehm and of 
Wartmann, it produces a gradual paralysis of the peripheral vagi, a 
constant increase of the intensity of a galvanic stimulation of the 
pneumogastric nerves being required to influence the heart as the poi¬ 
soning deepens, until finally the vagi entirely refuse to transmit any 
inhibitory impulse. 

In a single experiment, Achscharumow ( loc. cit., p. 272) found that 
after section of the vagi in the early stage of aconite-poisoning there 
was an immediate rise both in the number of the cardiac pulsations and 
in the arterial pressure. From these data he argues that the slowing 
of the pulse during the early stage of aconite-poisoning is due to stimu¬ 
lation of the inhibitory centres in the medulla oblongata. Boehm and 
Wartmann (loc. cit.) repudiate this conclusion, because, according to 
their experience, the phenomena of aconite-poisoning occur in the usual 
manner after section of the vagi, or in atropinized animals. It is evident 
that there is no necessary contradiction in the asserted facts of these 
observers, as it is possible that the slowing of the pulse may be due to 
two immediate causes, one having its seat in the medulla oblongata, 
the other in the heart. Although this explanation cannot be considered 
proved, it is probably correct. Professor Plugge confirms the state¬ 
ment of Boehm and Wartmann, that aconitine finally paralyzes the 
peripheral vagus, while Lewin agrees with Achscharumow that there 
is a primary rise of the pulse when aconitine is given after section of 
the vagi, but states that this rise is of very brief duration and is soon 
followed by the usual reduction ( Prager Vierteljahrs., Bd. cxxxi.). It is- 
very certain that aconitine also influences directly the heart or its con¬ 
tained ganglia, for Achscharumow (loc. cit., p. 262) has found that it 
acts upon the frog’s heart removed from the body, and Liegeois and 


CARDIAC DEPRESSANTS. 


411 


Hottot ( Journal de Physiologie, p. 520, 1861) have observed the ordinary 
cardiac phenomena of aconite-poisoning produced by the alkaloid 
placed directly upon the viscus. Boehm and Wartmann have also 
noted that in aconite-poisoning the force of the individual beat is les¬ 
sened. In the experiments of Laborde and Duquesnel, the cardiac 
beats were at first rendered very slow, but very full and forcible, and 
afterwards became very rapid and very feeble ( loc. cit.). After death 
the cardiac muscle fails entirely to respond to galvanic irritation, its 
contractility being lost.* 

Our knowledge of the action of aconitine upon the vaso-motor 
nerves is not complete. Achscliarumow, Dr. F. B. Nunneley ( Proc. 
Royal Society , p. 46, 1870), and still more recently Dr. Mackenzie, have 
studied with the microscope the influence of injections of aconitine 
upon the vessels of the frog’s web, but have been unable to detect any 
alteration of their calibre. The first observer has also found that after 
division of the sympathetic in the neck, galvanization of the periph¬ 
eral end produces the usual phenomena, even in the most advanced 
stages of aconite-poisoning. These facts indicate very strongly that 
aconite does not affect the vaso-motor nerves , and this indication is con¬ 
firmed by the experiments of Boehm and Wartmann, who found that 
when in aconite-poisoning a galvanic current was applied to the vaso¬ 
motor centres in the medulla, an immediate rise of arterial pressure 
took place. As stimulation of a sensitive nerve produced at such time 
no rise of arterial pressure, the conclusion would appear to be logical 
that aconitine, while not affecting the efferent vaso-motor nerves or 
the vaso-motor centres, destroys the conducting power either of the 
afferent nerves or of the cord, so that in an animal under its influence 
no impulse can be transmitted from the periphery to the vaso-motor 
centres in the medulla. 

Nervous System. —Such diverse experimental results have been 
reached by different investigators that it is very difficult to draw any 
positive conclusion from the evidence. Achscharumow concludes that 
the paralysis and loss of reflex activity induced depend upon the de¬ 
struction of the conducting power of the peripheral motor nerves, 
because ho has found that when a frog is poisoned after the abdominal 
aorta has been tied, reflex and voluntary activity is preserved in the 
hind legs long after it has been lost in the anterior portion of the body; 
and, at the same time, while the brachial nerves, as tested by galvanic 
stimulation, have lost their power of transmitting impulses, the pro¬ 
tected ischiatic nerves have preserved their functional ability. The 
very recent experiments of Professor P. C. Plugge ( Virchow's Archiv , 
Bd. lxxxvii. p. 410) confirm these experiments of Achscharumow, show- 


* Opposed to all this evidence are the extraordinary and at present inexplicable statements 
of Mackenzie ( Practitioner, xxi. 109), that aconitine has no effect upon the heart, and if 
applied directly to it does not seriously affect its pulsations. 



412 


GENERAL REMEDIES. 


ing, however, that it is the peripheral ends of the motor nerves which 
are affected, since, when in the frog’s leg the lower portion had been 
protected from the poison, galvanization of the nerve-trunk a con¬ 
siderable distance above the point of protection caused response in 
the tributary muscles. This concurrence of testimony would seem to 
prove that aconitine paralyzes the peripheral motor nerves. The testi¬ 
mony, however, to the contrary of this is strong. Boehm and Wart- 
mann in many experiments with Merck’s aconitine found that both the 
nerves and the muscles in poisoned animals preserve their normal ex¬ 
citability until death; they also determined that tying all the structures 
of a limb except its nerve did not prevent the usual development of 
paralysis when the poison was exhibited. In the elaborate research 
of Liegeois and Hottot, to be spoken of in detail directly, when all 
voluntary reflex actions were lost, the motor nerves and muscles were 
still found excitable. Mackenzie and A. Guillaud {Arch, de Physiol., 
1875) also bear testimony to the same effect. The explanation of this 
conflict of testimony is not to be found, as has been suggested by C. 
Ewers {Arch. f. Exper. Path. u. Pharm., i., 1873), in the use of different 
species of frogs, because Plugge employed various species; nor is it 
in the employment of different commercial aconitines, because Plugge 
experimented with all the varieties, and found them to vary in power, 
but not in quality of action. Those observers who have found least 
influence upon the motor nerves acknowledge some slight effect, and 
that when aconitine is brought in contact with an exposed nerve it 
rapidly destroys its functional activity; also that after death in the 
aconitized frog the motor nerves lose their irritability more rapidly 
than normal (Liegeois and Hottot, Guillaud, S. Linger and H. Murrell, 
Laborde and Duquesnel). Further, it has been noted that when in 
frogs the convulsions are very severe the motor nerves seem tempo¬ 
rarily to lose their functional power from exhaustion (Mackenzie). 
Mackenzie affirms (. Practitioner , xx. 186) that aconitine has a primary 
stimulant effect upon the motor nerve, and causes at first a distinct 
augmentation in the irritability both of nerve and of muscle. 

According to Dr. Liegeois and M. Hottot {loc. cit., p. 533), in aco¬ 
nite-poisoning loss of sensibility occurs in the frog’s legs simultaneously 
with or even before the disturbances of respiration, and long before the 
power of voluntary motion is lost, and even when the reflex activity is 
intact. This sensory paralysis, according to the experiments of the 
French investigators just quoted, first appears in the hind legs of a 
frog poisoned with aconitine, and has not its primary seat either in the 
peripheral nerves or in the spinal cord, for it was found that tying the 
aorta close to its abdominal bifurcation, so as to prevent access of the 
blood— i.e., of the poison—to the posterior nerves, did not affect the 
development of the anaesthesia; further, that closing the artery nearer 
its origin in such a way as to shut off the circulation to the cord and 
spinal nerves, but to allow the passage of the blood to the cerebrum, 


CARDIAC DEPRESSANTS. 


413 


did not cause sensory paralysis to come on more slowly than is normal 
in poisoning by aconite. 

Of course it is possible for the peripheral ends of the sensory nerves 
to be paralyzed either at the same time that the perceptive centre is, 
or afterwards; and of course, the centre being paralyzed, it becomes 
very difficult to determine whether the periphery is or is not affected. 
Liegeois and Hottot assert that this paralysis of the centre occurs 
before any serious implication of the peripheric nerves, because after 
aconitic anaesthesia had been produced strychnine was able to induce 
tetanus; afterwards, however, the extreme peripheric nerves became 
affected, so that irritation of the skin in the doubly-poisoned frog 
would not provoke convulsions, even at a time when irritation of the 
tt'unk of a nerve would produce general reflex motor disturbance. At 
last galvanization of the nerve-trunk itself failed to induce response. 
From these facts Liegeois and Hottot deduce—very logically, I think— 
the conclusion that aconite induces anaesthesia by paralyzing, first, the 
perceptive centres; secondly, the peripheral extremities of the nerves; 
thirdly, the nerve-trunks themselves. The observers just named also 
confirmed this conclusion by other experiments than those already 
noticed. They found that although aconitine applied directly to a 
nerve-trunk paralyzes its sensibility, yet when the veins of a frog’s 
leg are tied and the alkaloid injected into the artery and allowed to 
permeate the tissues of the leg, the skin loses its sensibility long before 
the nerve is affected. 

In regard to motion, Liegeois and Hottot found that in a certain 
stage of aconite-poisoning the frog lies with his limbs extended, re¬ 
laxed, and perfectly paralyzed, and yet is capable of executing vig¬ 
orous voluntary movements and evinces nearly normal reflex activity. 
They attribute this condition of apparent but not real motor paralysis 
to loss of sensibility from paralysis of the perceptive centre, as the 
unpoisoned frog evinces the same phenomena after division of all the 
posterior spinal roots. After a time the reflex activity is also lost, the 
power of voluntary movement remaining. Liegeois and Hottot believe 
that this loss of reflex activity is spinal; but in their experiments upon 
the conjoint action of aconite and strychnine it was found that at a 
certain stage, when no amount of irritation of a nerve would induce 
convulsions, a slight direct irritation of the cord would cause violent 
strychnic spasms. This would seem to show that at least the earliest 
abolition of the reflex activity was due to paralysis of the afferent 
nerve-fibres. 

In some particulars the researches of Liegeois and Hottot have been 
confirmed by the later studies of Hr. George Hunter Mackenzie (.London 
Practitioner, xx. 100). The persistence of voluntary movement after 
abolition of reflex actions, which was first noted by Boehm and Wart- 
mann, and afterwards by Liegeois and Hottot, as well as by Mackenzie, 
proves that at a certain stage of the poisoning, while the motor path- 


414 


GENERAL REMEDIES. 


way from the brain along the anterior columns and the efferent nerves 
is open, either the sensory nerves or the receptive centres of the cord 
are paralyzed. The experiments of Liegeois and Hottot upon the joint 
action of aconitine and strychnine are also accordant with those of 
Mackenzie, for that observer found that when a nerve was protected 
from the poison by tying its supplying artery, irritation of it caused 
reflex actions when the remainder of the frog’s periphery was insen¬ 
sible ; also that there is a stage of poisoning in which irritation of the 
extreme peripheral nerves fails to induce reflex movements, although 
such movements are called out by irritation of the sensory nerve-trunk ; 
later irritation of the trunk was powerless, while irritation of the pos¬ 
terior columns of the cord still produced wide-spread movements. It 
must therefore be considered proved that aconite paralyzes the sensory 
nerves , commencing at their peripheral endings , and that the loss of reflex 
activity is due, at least in great part, to such cause. 

The apparent contradiction between those investigators who have 
reached the conclusion just given and those who have found the motor 
nerves especially affected (see p. 412) can, it seems to me, be reconciled 
only by the theory that aconitine acts upon the peripheral ends both of 
sensory and of motor nerves: which nerve is most severely affected may 
possibly depend upon the size of the dose employed, or, more probably, 
upon the physical condition of the frog. The excessive numbness and 
tingling of the local and general action of aconitine upon man indicate 
that in the higher animals it especially affects the sensory nerve-endings * 

The supposed action of aconitine upon a higher perceptive centre is 
at present very doubtful. S. Einger and E. Murrell ( Journal of Physi¬ 
ology, i., Nos. 4 and 5) deny the accuracy of the delicate experiments 
of Liegeois and Hottot. Curiously enough, Drs. Einger and Murrell, 
while doubting the experiments of Liegeois and Hottot, accept the 
conclusions founded upon these asserted erroneous experiments, seem¬ 
ingly because they themselves have found that aconitine causes aboli¬ 
tion of reflex action more rapidly in brainless than in normal frogs. 
It is evident that even if this were invariably the case it would in no 
way prove the conclusions of Liegeois and Hottot. Further, the ex¬ 
periments on brainless frogs were only three in number, and it is per¬ 
fectly possible that the rapid reflex palsy was simply the result of 
batrachian idiosyncrasies. The only safe conclusion on the evidence is 
that the evidence does not warrant any conclusion. 


* Laborde and Duquesnel (Des Aconits, Paris, 1883, p. 103) believe that they have de¬ 
monstrated that aconitine does not act upon the sensory nerves. Their chief experiments 
consisted in tying the vessels of a dog’s leg in such a way that no blood could return to the 
body, and injecting the alkaloid into the limb, after cutting the nerve. Under these circum¬ 
stances they found that galvanization of the centric end of the nerve continued to elicit 
response. At most such experiments prove nothing as to the action of the poison upon the 
peripheral nerve-endings. Moreover, it remains uncertain whether the aconitine really came 
in contact with the divided nerve, as all circulation in the limb must have been arrested. 



CARDIAC DEPRESSANTS. 


415 


It is evident that we have not exact knowledge as to how aco¬ 
nite affects the nerve-centres ;* but the nervous phenomena of aconite¬ 
poisoning seem to me explainable by the action of the drug upon the 
sensitive and motor nerves. 

Respiration. —The action of aconite upon the respiration is very 
decided. In mammals the respirations, under the influence of the drug, 
are slow, with a prolonged expiration following immediately upon the 
inspiration. After the expiration there is a long pause. The whole 
breathing-cycle resembles very much that occurring after section of 
the vagi, and, like the alteration in breathing after this section, seems 
to be due at least in part to paralysis of sensory or afferent fibres. The 
known influence of aconite upon the peripheral afferent nerves in general 
suggests that the poison disturbs respiration by paralyzing the periph¬ 
eral afferent fibres of the vagi. Mackenzie states that in the aconitized 
animal section of the vagi produces no effect on the respiration; and 
Boehm and Wartmann (p. 127) affirm that aconite produces/ its usual 
effect after division of the nerves. It is plain that even if the aconite 
does paralyze the peripheral afferent vagi it must also act upon the 
respiratory centres, since arrest of respiration could not be caused by 
afferent palsy. As the arrest occurs in the frog before the motor nerves 
are affected by the poison, Liegeois and Hottot believe that the dis¬ 
turbance is centric; and I think there can be no doubt that aconite is 
a direct depressant and paralyzant of the respiratory centres .f 

Aconite lowers the bodily temperature in both man and the lower 
animals. Achscharumow found in fatal poisoning a fall of about 3° C.;{; 


* Experiments by Mackenzie on frogs have yielded apparently contrary results to those 
of Boehm and Wartmann as to the effect of removal of the influence of Setschenow’s centre 
upon the cord in aconitized frogs. The difference probably depends upon difference in the 
doses employed. Boehm and Wartmann distinctly state that when minute doses of aconitine 
are employed there is a primary period of excitement of the spinal centres. Mackenzie has 
found that the convulsions which are so severe in frogs after small quantities of aconite are 
chiefly of spinal origin, but that the peripheral motor apparatus shares the stimulation with 
the spinal motor tract. M. Guillaud ( loc . cit., p. 769) also affirms this primary stimulant 
spinal action. If it exists at all in mammals, it is in them completely masked. The convul¬ 
sions seen in aconite-poisoning in some mammals are cerebral, not spinal, as I have experi¬ 
mentally determined that they do not occur in those portions of the body separated by spinal 
section from cerebral influence. 

As Boehm and Wartmann found that the reflex activity was lost more rapidly than the 
power of voluntary movement, and that no increase of reflex activity occurs in the aconitized 
frog when the cord is cut so as to release it from the influence of Setschenow’s reflex inhibitory 
centres, they draw the conclusion that the aconitia first depresses the reflex activity of the 
sensitive spinal centres and afterwards that of the motor spinal centres, until the cord is 
completely paralyzed. 

f Laborde and Duquesnel affirm that after very large doses of aconitine the animal dies 
of spasm of the glottis and diaphragm, because they have noticed, especially in the young 
animal, drawing in or constriction of the lower chest during life, and sub-pleural ecchymoses 
after death. These are, however, the marks of paralysis of the glottis from palsy of the 
recurrent laryngeal nerve. 

J MM. Gr6haul and Duquesnel (L’ Union Pharm., Aug. 1871) have communicated to the 
French Academy some experiments upon frogs with crystallized aconitine, the results of 



416 


GENERAL REMEDIES. 


The reduction of the bodily heat is probably caused by an increase of 
heat-dissipation, itself in turn the outcome of a vaso-motor paralysis. 
In accord with this is the observation of Brunton and Cash ( St . Barthol. 
Hasp. Rep ., xxii., 1886) that in animals exposed to a high temperature, 
aconite, far from depressing the temperature, favors its increase, while 
when the animal is exposed to cold, aconite accelerates the fall of the 
bodily heat remarkably. 

Therapeutics. —Our knowledge of the physiological action of aco¬ 
nite, although imperfect, is sufficient to show that there are only two 
or three indications to meet which the drug may be used. 

The first of these is to lower arterial action , and often, with it, excess 
of temperature. For this purpose aconite is very valuable. I have 
never used it in those cases, such as pneumonia , in which a sudden and 
very powerful effect is desired, simply because veratrum viride seemed 
to me safer, more readily controlled, and equally effective. Aconite 
may, however, be used with very good results in these cases, and 
especially in such diseases as peritonitis , in which it is very important 
to avoid vomiting. My own experience with it has been in fevers of a 
sthenic type not dependent upon so deep-seated a cause (as an example 
may be mentioned the febrile movements of severe acute muscular rheu¬ 
matism) , and in the ephemera or irritative fevers of childhood: in such 
cases its influence for good is often very decided. In the early stages 
of scarlet fever and other exanthemata , when not decidedly adynamic in 
type, it is very useful. In the reflex fever which sometimes follows the 
passage of the catheter or bougie (the so-called urethral fever) it is very 
efficient.* * 

In some cases of hypertrophy of the heart , when the valves are per¬ 
fect, or when, the valves being diseased, the hypertrophy is greater than 
is necessary, aconite is of use to control cardiac excitement. When, 
however, there is dilatation of the heart or any degeneration of the 
heart-muscle, it is an exceedingly dangerous remedy, and it is at all 
times to be avoided if the hypertrophy be not excessive. 

A second indication which aconite might be used to fulfil is to allay 
spasm. As, however, its influence upon the motor centres and nerves 
is much less than upon the sensitive centres and nerves and upon the 
heart, the indication is better met by other remedies. 


which are so strikingly different from those of other experimenters as to indicate the existence 
of some fallacy: possibly the alkaloid used by them was not the same as the amorphous 
aconitine. They found in the frog, after small doses milligramme) of their alkaloid, that 
the heart continued to beat steadily and regularly after all power of spontaneous or reflex 
movement had been lost, that sensation was preserved as long as any power of motion existed, 
and that the motor nerve-trunks were paralyzed. After large doses (one milligramme) they 
observed sudden arrest of the heart’s action. These results are, however, entirely discordant 
with the later ones of Laborde and Duquesnel. 

* The following formula affords an excellent combination: R Tinct. coniti rad., gt. i; 
Sp. etheris nitrosi, fjii; Mist, potass, citrat., q. s. ad fji. S.—Dessertspoonful every two 
hours for a child three years old. 



CARDIAC DEPRESSANTS. 


417 


A third indication, which it would seem from its known physio¬ 
logical action that aconite should meet, is to relieve over-excitation of the 
sensitive nerves. Clinical experience has confirmed this. As long ago 
as 1834, Dr. Turnbull (On the Preparations and Medical Employment of 
Aconitina by the Endermic Method , London, 1834,— On the Medical Prop¬ 
erties of the Natural Order Panunculacece, London, 1835) called attention 
to the use of the alkaloid in neuralgia; and his estimate of its value 
has been confirmed by Dr. A. Fleming (An Inquiry into the Physiological 
and Medicinal Properties of the Aconitum Napellus, Edinburgh, 1845) and 
by other observers. 

In cases of rheumatic neuralgia dependent upon an acute exposure 
to cold and attended with more or less febrile disturbance, in combina¬ 
tion with other suitable remedies aconite is often of great service. In 
chronic neuralgia , associated as it always is with a lowered systemic 
tone, the remedy is less efficient; yet in some cases it seems to give 
relief. Owing to its very marked local benumbing influence, applied 
to the painful part it is sometimes very useful. In my own expe¬ 
rience, this local use of it has, however, very seldom been effective 
when, as in migraine, the pain is of centric rather than of peripheral 
origin. 

Given in full doses in the reflex vomiting of pregnancy , aconite is 
often advantageous, acting probably by benumbing the sensory reflex 
centres, or possibly the afferent peripheral nerves. I have noticed that 
relief lasts only so long as decided constitutional effects from the drug 
are apparent. 

Toxicology. —Aconite is an exceedingly powerful poison; one- 
twelfth of a grain of the crystallized alkaloid is, according to Duques- 
nel, sufficient to kill a rabbit in a short time. Five grains of an ex¬ 
tract and eighty minims of a tincture are said to have caused death 
(Reichert, Pliila. Med. Times , Hov. 1881, p. 105). The symptoms usually 
come on in a very few minutes. In the shortest case I have met with, 
death occurred in thirty minutes. The average time of death (Reichert, 
loc. cit .) is three and a third hours; the longest recorded case being five 
and a half hours. 

The aconitines of commerce vary inordinately in strength, so that 
while one-sixteenth of a grain (prepared by Petit,* of Paris) caused 
the death of Dr, Carl Meyer in five hours, several grains of the im¬ 
pure article so largely sold have been recovered from. The symptoms 
have been in general those of aconite-poisoning, but excessively vio¬ 
lent pains and convulsions have been very marked features of some 


* In the researches of Anrep, Duquesnel’s crystallized aconitine was nearly twice as 
strong as a German alkaloid used by him, which in turn was much stronger than an English 
article. Plugge found Petit’s aconitine eight times as strong as that of E. Merck. Langgard 
found an alkaloid prepared from A. japonicum exceedingly powerful. The best discussions 
of the relative strength of these alkaloids that I know of may be found in Schmidt’s Jahrb., 
ccii. 124, and in Des Aconits , by Drs. J. V. Laborde and H. Duquesnel, Paris, 1883. 

27 



418 


GENERAL REMEDIES. 


of the cases. (For a very valuable general discussion of aconitine¬ 
poisoning, by Dr. Thomas Stevenson, see Guy's Hospital Reports, 3d 
series, xxvi. 308.) 

The peculiar tingling is the only diagnostic symptom, but it is 
very characteristic. The first indication for treatment is to evacuate 
the stomach and wash it out well with the stomach-pump. Alcoholic 
stimulants should be freely administered, hot and concentrated, and 
alcohol, ether, and digitalis be given hypodermically; the injection of 
ammonia into the veins may be practised. Great care should be used 
to keep the patient absolutely quiet, upon the back, with the feet a 
little higher than the head. Laborde and Duquesnel affirm that in the 
lower animals death after a usually fatal dose of aconitine can be pre¬ 
vented by artificial respiration; and in a case of human poisoning, if 
the heart’s action were at all sustained, and the respiration failing, 
Silvester’s method might be resorted to. 

It was discovered by Dr. J. Milner Fothergill ( Digitalis, London, 
1871, p. 6) that in the aconitized frog, even when cardiac action has 
ceased, digitalis has power to recall the systolic movements. More re¬ 
cently this antagonistic action of aconite and digitalis upon the frog’s 
heart has been abundantly proved by various experimentalists. Clin¬ 
ical experience, although still limited in extent, strongly corroborates 
the experimental evidence of the value of digitalis. Successful cases 
may be found in Brit. Med. Journ ., Dec. 11,1872 (f^i Fleming’s tincture, 
Tinct. digitalis ttjjx hypodermically) ; Bost. Med. and Surg. Journ., Oct. 
1879, 544 (foiii Tinct. aconit. rad., Tinct. digitalis ttjjlx hypodermically) ; 
Indian Med. Gaz., xvii. 323 (Aconitum ferox root, 48 grains, Tinct. digi¬ 
talis njjxxv hypodermically and f3i by mouth); Phila. Med. Times, xiii. 
328 (a decoction of aconite, amount unknown, Tinct. digitalis in drachm 
and half-drachm doses, by mouth). In a successful case treated by Dr. 
Elliot (Lancet, 1878, ii. 917) nitrite of amyl freely inhaled seemed to 
do great good: a fluidounce of a concentrated aconite liniment was 
thought to have been taken. Ammonia injections were unsuccessful 
in a case reported in the Australian Med. Journ., 1879, i. 283. 

Administration. —Aconite is never used in substance. The dose of 
the tincture of aconite (Tinctura Aconiti —1 to 2.5, U.S.) is one to five 
drops, repeated every one to three hours pro re nata, its effects being 
always watched. Fleming’s tincture is a stronger preparation (£xss 
to Oj). 

The dose of the extract (Extractum Aconiti, U.S.) is one-quarter to 
three-quarters of a grain; of the abstract (Abstractum Aconiti, U.S.), 
one grain; of the fluid extract (Extractum Aconiti Fluidum, U.S.), one 
to two minims. The tincture or the fluid extract of aconite is very 
frequently added to stimulating and anodyne liniments. 

Aconitine is not officinal, and, on account of its intense activity, 
should not be given internally: even its external use requires care. 
The ointment may be of the strength of two grains to the drachm: a 


CARDIAC DEPRESSANTS. 


419 


two-per-cent, solution of the oleate of aconitine in oil has been highly 
commended as a local application in neuralgia. 

ACIDUM HYDROCYANICUM—HYDROCYANIC ACID. 

Pure hydrocyanic acid is a colorless, transparent, volatile, inflam¬ 
mable liquid, giving rise to giddiness and headache when smelled, and 
having, it is said, a burning, bitter taste. So poisonous is it that when 
inhaled it causes death, and it must be handled with the greatest 
caution: smelling and tasting it are excessively dangerous proceedings. 
It is, indeed, an imperative rule that no one should experiment with 
anhydrous prussic acid alone, or under any circumstances in summer, 
or in a warm room, or in an apartment whose open windows and 
doors do not admit of a free draught of air. The chemist Scheele, the 
discoverer of prussic acid, is believed to have been killed by the in¬ 
halation of the fumes of this material, whose poisonous properties 
were first pointed out by the Berlin apothecary Schrader in 1803. The 
anhydrous acid is soluble in water and in alcohol, but is never kept in 
the shops, and is not officinal. 

Hydrocyanic acid of common medical parlance is the officinal Dilute 
Hydrocyanic Acid (Acidum Hydrocyanicum Dilutum, U.S.), a colorless, 
watery solution, containing two per cent, of the anhydrous acid. Its 
odor and taste are the familiar ones of peach-kernels and bitter almonds; 
its reaction is faintly acid. According to the directions of the U.S. 
Pharmacopoeia, it is prepared by distilling a mixture of ferrocyanide 
of potassium, sulphuric acid, and water, or by precipitating cyanide of 
silver from its watery solution with hydrochloric acid. With solution 
of nitrate of silver added in slight excess, one hundred grains of it pro¬ 
duce a white precipitate, which, when washed with water until the 
washings are tasteless, and dried at a temperature not exceeding 212°, 
weighs ten grains, and is wholly soluble in boiling nitric acid. 

The precipitate in this case is the cyanide of silver, and the amount 
afforded shows that the liquid contains the officinal percentage of an¬ 
hydrous prussic acid. 

As hydrocyanic acid has a great tendency to undergo spontaneous 
decomposition, especially under the influence of light, it should be kept 
in well-stopped, dark-colored bottles. 

Physiological Action. —In warm-blooded animals, poisoning by 
hydrocyanic acid divides itself naturally into the acute and the sub¬ 
acute,—death occurring in the first in at furthest ten minutes, in the 
second not at all, or else only after the lapse of a longer time than 
that noted. After a full dose of the strong anhydrous acid, the animal 
gasps once or twice, and then instantly falls in a tetanic or clonic 
convulsion, or else drops motionless and powerless upon its side. In 
either case, at once the signs of asphyxia manifest themselves, and 
grow more and more intense, until they end in total arrest of respira¬ 
tion. The heart beats irregularly, often at first slowly and strongly. 


420 


GENERAL REMEDIES. 


with intervals of suspension of movement, but always becoming weaker 
and more rapid in its action, until, after the breathing has ceased, its 
efforts gradually die away. If the dose has been enormous, the heart 
and lungs may stop acting at once; otherwise the cardiac pulsations 
may continue some minutes after the arrest of respiration. Ordinarily, 
three distinct stages are apparent: a first, very brief one, of difficult 
respiration, slow cardiac action, and disturbed cerebration; a second, 
convulsive stage, with dilated pupils, violent convulsions, unconscious¬ 
ness, loud cries, vomiting, often spasmodic urination and defecation, 
erections, etc.; and a third period, of asphyxia, collapse, and paralysis, 
sometimes interrupted by partial or even general spasms. 

The slow form of the poisoning follows the exhibition of the poison 
in an amount just sufficient to kill. After the ingestion of such a dose, 
no phenomena are offered for some seconds; then the breathing becomes 
labored, and the pulse slow and full. The animal perhaps cries out, and 
muscular tremblings invade the whole body, to give place, in a very 
short time, to clonic and tonic convulsions, which continue at intervals 
until the third stage, that of collapse, is developed. The convulsions 
are less violent and less frequent than those of the acute poisoning; all 
the symptoms noted as occurring during the second stage of rapid 
cases are present in the corresponding period of the subacute poi¬ 
soning, although less violent and less intense in their manifestations. 
When the third stage is developed, the anaesthesia is marked, affecting 
first the hind legs, but finally spreading to all parts of the body, and 
even being complete in the widely-dilated pupil. Death finally results 
from failure of respiration. Recovery may occur even after the con¬ 
junctiva has lost its sensibility; the return to life by a subsidence of 
the symptoms is usually rapid, so that generally in from one-half to 
three-quarters of an hour the animal will be eating as though nothing 
had happened. Coullon. however, noted persistence of paralysis, in 
some cases, for days. 

In man, prussic acid produces results closely parallel with those 
which it causes in the lower animals. The symptoms come on suddenly. 
In a moment or two the individual falls to the ground insensible and 
convulsed, the respirations arrested or occurring at long intervals, the 
eyes salient, the pupil dilated, the mouth covered with bloody froth. 
If the dose be sufficiently large, death may occur in three or four 
,minutes; if less has been taken, deep insensibility, tetanic or clonic 
convulsions, dilated pupils, a bloated countenance, cyanosed surface, 
set jaws, and irregular respiration, constitute the chief symptoms. 
The breathing is mostly convulsive, with deep, forcible expirations, 
but in some cases it has been stertorous. Death results from asphyxia. 
After small toxic but not lethal doses of prussic acid, giddiness, light¬ 
ness of the head, nausea, a quick pulse, an'd muscular weakness are the 
chief symptoms. 

Action on the Blood .—As early as 1814, Dr. F. B. Yietz {Med. Jahrb. 


CARDIAC DEPRESSANTS. 


421 


d. k. k. Oesterreich. Siaates, Bd. ii., 1814) called attention to the change 
of color that occurs in the venous blood of animals poisoned with 
prussic acid; and his observations have been confirmed by E. L. Schu- 
barth ( Horn's Archiv f. Med. Erfahrung , Berlin, 1824), by J. F. Sobern- 
heim ( Hcindbuch der Prakt. Toxicologie , Berlin, 1838), and by Dr. Coze 
(Gazette Medicale de Paris , 1849). In his Legons sur les Substances 
toxiques, p. 193 (Paris, 1857), Claude Bernard reaffirms the occurrence 
of these changes, and further states that if the animal dies suddenly 
the blood in the veins and right heart is found of a bright arterial hue 
at the post-mortem. Notwithstanding all this testimony, J. R. Bischoff 
( Ueber Vergiftungen nebst einigen Versuchen an Thieren, welche mit Blau- 
saure , etc., Wien, 1844) and numerous other observers have found that 
after death from prussic acid, either in man or in other mammals, noth¬ 
ing but dark venous blood exists in the body. Of the correctness of 
this observation there can be no doubt. 

Professor W. Preyer ( Die Blausaure , Bonn, 1870) has afforded by 
his experiments an explanation of these apparently contradictory facts. 
He found that directly after the exhibition of prussic acid to a mammal 
the blood becomes, even in the veins and in the right heart, of a bright 
arterial hue, but that after a time this color darkens into the blue of 
venous blood, and finally, even in the arteries and in the left ventri¬ 
cle, only blood of such character is to be found. Dr. Carl Gaethgens 
(Hoppe-Seyler’s Medicin.-chem. TJntersuchungen, Berlin, 1866, p. 324) has, 
in a number of experiments, confirmed this, so it must be accepted as 
a fact. When an animal dies suddenly from cardiac paralysis, during 
the first stage of poisoning, this excessive arterialization may be found 
after death, as mentioned by Claude Bernard; and, as Preyer first 
noticed, in cold-blooded animals the bright color persists for many 
hours. By spectroscopic examination Professor Preyer (loc. cit., p. 95) 
found that the dark blood of prussic acid poisoning is absolutely or 
almost free from oxygen, showing only the absorption bands of deoxi¬ 
dized haemoglobin, while Gaethgens (loc. cit., p. 328) has discovered that 
the red venous blood of the first stage of the poisoning shows very 
clearly the absorption bands of oxyhaemoglobin. The first question 
which arises at this juncture is as to the causes of these changes of 
the blood, its primary excessive arterialization, its secondary excessive 
carbonization. Professor Hoppe-Seyler affirms ( Medicin.-chem. TJnter- 
suchungen , p. 140, Berlin, 1867) that the appearance of red blood in the 
veins is because the red blood-corpuscles have been so acted upon by 
the poison as to have lost their ability of yielding up their oxygen in 
the capillaries. Dr. Carl Gaethgens (Ibid., p. 325) has by an elaborate 
series of experiments shown that in the first stage of prussic acid 
poisoning much less than the normal amount both of carbonic acid and 
of exhaled oxygen is eliminated. The lessened exhalation of oxygen 
probably depends simply upon a lessened inhalation of oxygen, owing 
to the disordered respiration. That the lessened excretion of carbonic 


422 


GENERAL REMEDIES. 


acid is not due to the same cause, however, is shown by the fact, de¬ 
termined by Gaethgens (loc. cit., p. 347), that the percentage of the 
acid in the expired air is less than normal, while that of oxygen is 
greater than normal. It is evident that if the lessened excretion of 
carbonic acid were produced by the entrance into the lungs of an 
amount of air insufficient for the wants of the system, the expired air 
would contain more than its normal proportion of carbonic acid and 
less than its normal amount of oxygen. The observed phenomena 
seem to me to prove that during the first stage of prussic acid poison¬ 
ing oxidation is arrested. They do not demonstrate, however, that the 
arrest is due to a direct action of the poison upon the blood-corpuscles. 
The probabilities of such occurrence are rendered very slight by the 
investigations of Gaethgens himself, for he found that when the experi¬ 
ments were prolonged from seventeen to forty-four minutes, much more 
than the normal amount of carbonic acid was exhaled, a fact in accord 
with the excessive carbonization of the blood known to take place in 
protracted hydrocyanic acid poisoning. As it seems incredible that 
a substance should one minute paralyze the ozonizing power of the 
blood-corpuscles and the next minute increase it, it is very improbable 
that the super-arterialization of the blood in the first stage of prussic 
acid poisoning is due to a direct action of the poison upon the red 
disk. 

Preyer has proved (loc. cit., p. 85) that when to blood at the tem¬ 
perature of the body hydrocyanic acid is added, the spectrum after a 
time is altered and new absorption bands appear. These bands are due 
to the formation of a new compound by the union of the haemoglobin 
and the hydrocyanic acid. This substance, cyanohcemoglobin, was first 
discovered by Hoppe-Seyler ( Virchow's Archiv, Bd. xxxviii. p. 475), 
and has no ozonizing power whatever; to its formation, no doubt, is 
owing the loss of ozonizing power by blood to which hydrocyanic acid 
is added outside of the body, a phenomenon pointed out by Schonbein* 
(Schmidt's Jahrbucher, 1868, Bd. cxl. p. 161), and indicated even earlier 
by the researches of Professor Harley (Lond. Phil. Trans., 1865, p. 
706).f The latter observer found that the blood taken out of the 
veins of a subject forty-eight hours after death from prussic acid poi- 

* In the same memoir Schonbein calls attention to the fact that hydrocyanic acid destroys 
also the ozonizing power of living vegetables, such as roots, fungi, etc. 

f According to Dr. B. Ray Lankester ( PJluger’s Archiv, 1869, p. 492), when blood is 
shaken with cyanogen gas, and allowed to stand for two or three hours, the spectrum-changes 
are exactly the same as after similar treatment of blood with CO. The compound of cyanogen 
and haematin (Cy,Hb) offers not only the identical spectrum of CO,Hb, hut also, like the latter, 
is unaffected by reducing agents. After the blood stands awhile, according to Dr. Lankester, 
the spectrum of hydrocyanic acid (H,CN) becomes visible in it, and the Cy,Hb undergoes 
conversion into the cyanohaemoglobin (Cy,Hb) of Hoppe-Seyler. 

Any one desirous of investigating this subject more deeply than can be done in a work 
like the present should consult especially the papers by Hoppe-Seyler, Virchow’s Archiv, Bd. 
xxxviii., and scattered through the Med.-chem. Untersuchungen ; by Harley, Lond. Phil. 
Trans., 1865, p. 706; and by Preyer, PJluger’s Archiv, 1868, p. 395. 



CARDIAC DEPRESSANTS. 


423 


Boning, and thoroughly arterialized by shaking with air, and then 
allowed to stand, yielded gas containing 19.56 parts of oxygen, 80.44 
parts of nitrogen, and 0.00 parts of carbonic acid. 

These facts at first sight seem to prove the theory of Hoppe-Seyler, 
to which indeed they no doubt gave origin. Preyer has shown ( loc. cit., 
p. 95), however, that the dark blood of prussic acid poisoning has not 
lost its power of oxidization, for on being shaken with the air it as¬ 
sumes the red arterial hue; and Drs. Lecorche and Meuriot ( Archives 
Gen., 6e serie, t. xi. p. 539) have determined that artificial respiration 
will produce the same result in the poisoned animal. Moreover, the 
spectroscope shows plainly that the htemoglobin exists in the blood 
either in its pure state (Preyer, loc. cit., p. 95) or else as oxyhsemo- 
globin (W. Laschkewitsch, Reichert's Archiv, p. 652, 1868; Hiller and 
Wagner, Lancet, 1877, vol. ii. p. 933), and that no cyanohsemoglobin is 
present. The reaction between hydrocyanic acid and haemoglobin is 
one requiring some time, and evidently does not occur in poisoning. 
On the whole, therefore, I think that the chemical evidence clearly 
shows the falsity of the theory that prussic acid acts in the body directly 
upon the red blood-corpuscles. 

Preyer (loc. cit., Theil ii. p. 88) has shown that the excessive oxy¬ 
genation and the subsequent excessive carbonization of the blood are 
not peculiar to hydrocyanic acid poisoning, but are equally present 
after the exhibition of sulphuretted hydrogen, and even after mechan¬ 
ical closure of the mou^h and nose. It is possible that an increased 
arterial pressure, an increased rapidity of circulation, may cause the 
blood to pass too quickly through the capillaries to allow time for the 
usual changes; but this has not been proved, and at present it must be 
acknowledged that we are ignorant as to the immediate cause of the 
blood-changes in these cases. 

It is possible, although scarcely probable, that the changes in the 
color of the blood are due to alteration in the form of the corpuscles. 
According to Ernst Geinitz ( Pfluger's Archiv, 1870, Bd. iii. p. 46), out¬ 
side of the body prussic acid produces in the blood-corpuscles of the 
frog, first, a shortening of the long and a lengthening of the short 
diameter, and consequently a rounded form, then granulations, and 
finally a solution and setting free of the nucleus. In frogs poisoned 
with prussic acid a rounded form of the corpuscles was commonly ex¬ 
hibited, and sometimes granulations were present. M. Geinitz also 
found that the red disks of mammalian blood, exposed to the vapor 
of hydrocyanic acid in the moist chamber of Strieker, become first 
somewhat asymmetrical, then mulberry-shaped, and finally undergo 
molecular destruction. In poisoning of mammals, according to the 
same investigator, the granular blood-corpuscles are commonly met 
with. Preyer (loc. cit., Theil ii. p. 91) confirms the observation of 
Geinitz so far as the action of the poison upon drawn blood is con¬ 
cerned, but both he and Hiinefeld (Lev Chemismus in der thierischen 


424 


GENERAL REMEDIES. 


Organisation , Leipsic, 1840) assert that immediately after death from 
prussic acid the corpuscles offer their usual characters. 

Whatever may be the cause of the changes in the blood, the experi¬ 
ments of Lewisson ( Reichert's Archiv , 1870, p. 352) would appear to 
prove that the action of the poison on the nervous system is a direct 
one, and not due to these changes in the vital fluid, for the observer 
mentioned found that prussic acid acted upon the bloodless “salt frog” 
as upon the normal batrachian. 

Action on the Heart. —The action of hydrocyanic acid upon the heart 
varies according to the dose. In sufficient amount and concentration it 
produces instantaneous diastolic arrest, which is either permanent or 
reoccurs after a few slow feeble beats (Preyer, loc. cit., p. 52, and Drs. 
Lecorche and Meuriot, Archives Gen., 6e serie, t. xi. p. 543). As early 
as 1826, Krimer found that prussic acid placed directly upon the heart 
of the frog produces arrest of its beat and loss of its muscular irrita¬ 
bility. Preyer has confirmed this, and it would seem to be proved that 
the cardiac arrest spoken of above is due to a direct action upon the 
heart-muscle or its contained ganglia, yet that after cardiac death from 
prussic acid the heart responds to galvanism. 

The cardiac results of the exhibition of small non-toxic doses are, 
according to Preyer, simply slowing of the heart’s action. 

Preyer and Lasehkewitsch agree as to the action of large, but not 
enormous, doses. At first there is a sudden prolonged diastolic arrest 
of the heart, followed by an augmentation in ttye rapidity of the cardiac 
action, and after this a diminution of the rate,—to the normal number 
in cases of recovery, to cardiac stand-still in cases of death. Both 
Preyer* and Lasehkewitsch ( Reichert's Archiv , 1868, p. 653) found that 
after section of the vagi the primary diastolic arrest of the heart did 
not occur. The recent investigations of Jos. Lazarski confirm the 
statements of Preyer as to the action upon the vagus. A complete in¬ 
hibitory arrest of the heart was rarely achieved, yet slowing of the 
pulse was constantly produced by moderate doses of the poison in the 
normal animal, but was prevented by previous section of the vagi, and 
was removed, when present, by division of the inhibitory nerves ( Wien. 
Med. Jahrb., 1881, 141). It would seem, therefore, proved that small 
doses of prussic acid stimulate the cardiac inhibitory nervous centres. 
Boehm and Knie noted that large doses of the acid caused slowing of 
the pulse whether the vagi were cut or not (. Archiv fur Exper. Path, und 
Therap ., ii. 137), and in this have been confirmed by Lazarski. This 
slowing would seem to be due to a direct action upon the muscle or 
the intra-cardiac ganglia, as Lazarski found that the cardiac accelerator 
nerves are not paralyzed. 

Moderate doses of prussic acid seem to produce a primary very brief 


* Preyer (loc. cit., p. 93) has also noted the same absence in curarized animals poisoned 
by hydrocyanic acid. 



CARDIAC DEPRESSANTS. 


425 


but great rise in the arterial pressure, followed by a fall to or below the 
normal. This primary rise has been noticed by Boehm and Knie, by 
TV ahl (De Vi et Effectu Hydrocyanato ad Curationem attrib., Bonn, 1865), 
by Rossbaeh and Papitzky ( Centralbl.f . Med. Wissens ., 1877, p. 640), and 
by Lazarski. It does not seem to be altogether the result of the as¬ 
phyxia produced by the acid, as it is recorded by Boehm and Knie ( loc . 
cit., p. 146) as occurring when artificial respiration was used, and La¬ 
zarski has confirmed this. All observers agree that it is followed, if 
the dose of the poison has been large enough, by a profound sinking of 
the arterial pressure. Lazarski found that galvanization of a sensitive 
nerve has no etfect at this time upon the blood-pressure: so that we 
must consider that hydrocyanic acid primarily stimulates very briefly the 
vaso-motor system directly or indirectly, and afterwards paralyzes it. 

Action on Respiration. —According to Preyer (loc. cit., pp. 17, 18, 19), 
during all three stages of hydrocyanic acid poisoning the respirations 
are lessened in frequency, and during the latter moments of life the 
efforts at breathing are very distant, and finally cease before the arrest 
of cardiac movements. The observer just mentioned found that, after 
division of the vagi, normally lethal doses did not kill, and that when 
death was brought about by the exhibition of larger doses it was by 
cardiac arrest. From this he deduces the conclusion that the prime 
respiratory action of the poison is upon the peripheral ends of the vagi. 
Dr. Preyer’s experiments have been partially confirmed by Drs. Lecor- 
che and Meuriot (loc. cit., p. 538) ; but Boehm and Knie (Archiv f. Exper. 
Path. u. Therap., Bd. ii. p. 135) have in a series of experiments found 
that section of the vagus has no influence upon the respiratory action 
of the poison, and in this have been confirmed by Jos. Lazarski (loc. 
citi). Even if investigations had proved the correctness of Preyer’s 
experiments, his conclusion could not be considered established, because 
we know so imperfectly the nonnal relations of the pneumogastrics to 
respiration. Moreover, Professor Joseph Jones (New York Med. Record, 
vol. ii. p. 459) found that while to kill an alligator by the administra¬ 
tion of prussic acid required a considerable length of time, its applica¬ 
tion to the medulla produced within one minute a most powerful expi¬ 
ration, ending in permanent contraction of the muscles of respiration 
and collapse of the lung. We must, it seems to me, at present consider 
that the respiratory phenomena of prussic acid poisoning are due to an 
influence exerted directly upon the respiratory centre. 

Action on Muscles and Nerves and Nerve-centres. —Dr. Kolliker ( Vir¬ 
chow’s Archiv, Bd. x. p. 272) has found that in frogs dead of prussic 
acid poisoning both the nerve-trunks and the muscles are unexcitable, 
or that the muscles respond very feebly to direct stimulation. This is 
in accord with the experiments of Stannius (Reichert's Archiv, 1858, p. 
95), who found that when strychnine and prussic acid were given to¬ 
gether, the convulsions normally produced by the former poison were 
altogether absent, or present only in a slight degree. In order to deter- 


426 


GENERAL REMEDIES. 


mine whether the nerves are or are not primarily affected, Kolliker ex¬ 
perimented by tying the vessels of the thigh, then dividing just below 
this point all the tissues except the nerve, and administering prussic 
acid by the mouth. In a number of such experiments he found that 
always the nerve and muscles below the point of section retained their 
irritability, but that when the galvanic or other stimuli were applied 
to the nerve higher up, they failed to elicit any response from the un¬ 
poisoned tributary muscles,—positive proof that the nerve-trunks are 
paralyzed by a direct action of the drug. This is seemingly opposed 
to the experiments of Stannius (loc. cit.), who concluded that prussic 
acid applied locally to the nerves has no effect upon them. Stannius, 
however, compared the results of soaking a nerve in water and in a 
weak solution (three to four per cent.) of prussic acid, and found that 
water thus employed is toxic to the nerve-trunks. Kdlliker used, in 
repeating the experiments of Stannius, neutral solutions of phosphate 
of sodium, one containing, the other free from, hydrocyanic acid, and 
found that the nerves in the poisoned liquid died much sooner than did 
those in the non-poisoned solution. 

The experiments of Kolliker are in agreement with those of Stan¬ 
nius, that the muscle dies very much more quickly in the solution of 
the acid than does the nerve, losing its excitability in from seven to 
eight minutes. This rapid destruction of muscular irritability by the 
local application of prussic acid was, I believe, first noted by Coullon 
in 1819. Yet it is most probable that when given internally prussic 
acid acts almost as rapidly upon the nerve-trunks as upon the muscles, 
since Kolliker noted that in some cases galvanization of the nerve was 
incapable of causing contractions in the tributary muscles, although 
the latter responded feebly to direct stimulation. This fact has been 
experimentally corroborated by Funke (Berichte uber die Verhandl. d. k. 
sachs. Gesellschaft d. Wissensch. zu Leipzig , 1859, Bd. xi. p. 28). 

Upon the peripheral sensitive nerves prussic acid probably, if in 
sufficient concentration, acts as a paralyzant ; at least Kdlliker {loc. cit., 
p. 282) found that if the leg of a strychnized frog, whose heart had 
been cut out to prevent absorption, was put in a four-per-cent, solution 
of prussic acid, in a very short time irritation of the immersed skin 
ceased to produce convulsions. 

From the slowness with which, in Kolliker’s experiments, the nerve- 
trunks were affected in frogs poisoned by hydrocyanic acid, it seems 
probable that he is correct in his conclusion that in these batrachians 
the poison first paralyzes the brain, then the reflex centres of the 
spinal cord, and afterwards the motor nerves. But I have not met 
with any experimental evidence in regard to the order in which prussic 
acid affects the nervous system. According to Kiedrowski,* as quoted 


* I have, unfortunately, been unable to obtain access to the original paper of E. de Kie¬ 
drowski. Even Preyer appears to know it only in abstract. According to him, it was pub- 



CARDIAC DEPRESSANTS. 


427 


by Preyer, in frogs it first paralyzes the gray, then the white sub¬ 
stance of the brain, and the early disappearance of reflex movements 
is not due to spinal palsy, but to destruction of the functional power 
of the peripheral afferent nerves. Preyer also states that the conclu¬ 
sions of Kiedrowski rested upon the following experimentally-proved 
fact, which, if accurate, seemingly renders them logically inevitable. 
When a frog is poisoned with prussic acid, and afterwards with strych¬ 
nine in properly-proportioned doses, there is a stage at which slight irri¬ 
tation of the afferent nexwe-roots causes violent general tetanic spasms, 
although the most intense peripheral irritation fails to elicit response. 

It is a question of interest to decide as to the cause of the convul¬ 
sions in poisoning by hydrocyanic acid. I have found that they do not 
occur after section of the cord in parts below the point of section, and 
that they are therefore cerebral in origin: for reasons detailed else¬ 
where (see p. 384), it is very probable that they are due to disturbed 
cerebral circulation, and this probability is confirmed by an experiment 
of Laschkewitsch ( Reichert's Archiv, 1868), who opened the thorax of 
a rabbit so as to expose the heart, maintained artificial respiration, and 
administered prussic acid; directly after arrest of the heart had com¬ 
menced, the convulsion came on. The earlier observation of Coze 
( Comptes-Rendus , 1849, t. xxviii. p. 780) is also to the same effect, as he 
states that the convulsions did not occur until directly after the arrest 
of the circulation. In frogs poisoned with hydrocyanic acid, convul¬ 
sions do not take place. Preyer states that after section of the vagi 
convulsions do not generally happen in mammals, but if artificial res¬ 
piration be performed they come on (loc. cit ., p. 69). 

Therapeutics. —Our knowledge of the physiological action of prussic 
acid does not lead to a belief in its wide applicability to the relief of 
disease, and I think clinical experience has demonstrated that it is of 
little value except in meeting three indications: first, to allay cough; 
second, to relieve irritation of the gastric nerves; third, to allay irritation 
of the ■peripheral sensitive nerves. 

There appears to be in the profession a very wide-spread belief in 
the power of this remedy to allay cough; at least it is very largely 
used for this purpose in cough-mixtures, either itself or in the form of 
cyanide of potassium. I have employed it in a great number of cases 
in hospital practice, and apparently with good effect, although, as it 
was always given in combination with such remedies as morphine, it is 
difficult to say how much of the result was due to it. I do not believe 
it can compare with such narcotics as opium or hyoscyamus in its 
ability to fulfil the present indication. 

There can be, on the other hand, no doubt as to the value of prussic 
acid in certain stomachic affections, especially nervous vomiting and 


lished in 1858, at Breslau, as a dissertation, under the following title: De quibusdam experi¬ 
ments quibu8 quantum vim habeat acidum hydrocyanicum in nervorum ay sterna cerebro-spinale 
atque in musculos aystematia vertebralia probatur. 



428 


GENERAL REMEDIES. 


gastralgia. When the pain is accompanied by decided dyspeptic symp¬ 
toms, the remedy will sometimes succeed, but more often fails. Even 
in the most favorable cases it does not always afford relief; and as the 
relief when it does occur is immediate, or at least is very soon appar¬ 
ent, it is useless to persist long in the exhibition of the remedy. In 
these cases its action is probably local, as it certainly is when the acid 
is employed to relieve itching in prurigo and other cutaneous diseases. 
For this purpose it is used as a wash (fjss to f$i in foi); but great 
care must be taken to avoid constitutional effects, especially when there 
is any abrasion of the skin. Very serious results are said to have been 
caused by its absorption when carelessly used in skin-diseases. 

Prussic acid has been commended as an arterial sedative; but it is 
evident that we possess numerous more efficient and far safer remedies 
of such character. 

Toxicology. —The symptoms of prussic acid poisoning have already 
been mentioned: those of most value from a diagnostic point of view 
are the sudden occurrence of unconsciousness; the violent convulsions; 
the general paralysis; the peculiar character of the breathing, expira¬ 
tion being prolonged and forced; and the rapid results. The odor of 
prussic acid upon the breath is very often, but by no means always, 
present. When distinct, it is, of course, of very great diagnostic 
value. Leaving out of sight the cyanides, the only poison with which 
prussic acid could well be clinically confounded is nitro-benzole. The 
distinction is often very difficult, large doses of the latter substance 
killing almost as quickly as prussic acid, and inducing analogous symp¬ 
toms. Caspar advises that after death the body be left open, exposed 
to the air, as the odor of prussic acid disappears rapidly, while that of 
nitro-benzole is persistent. The diseases with which the poisoning may 
be confounded most readily are some forms of apoplexie foudroyante, and 
sudden failure of the heart’s action. The diagnosis may, during life, 
be almost impossible. It has been asserted that stertorous breathing 
does not occur in prussic acid poisoning; but it has been present in 
several reported cases. (See Taylor's Medical Jurisprudence, Philadel¬ 
phia, 1873, p. 363.) An autopsy, however, ought generally to enable 
the physician to determine whether the case has or has not been one 
of prussic acid poisoning, if the symptoms during life are known. 

A curious case of temporary hemiopia, apparently caused by the 
fumes of hydrocyanic acid, is reported in Brit. Med. Journ ., 1884, i. 409. 

The period at which death may occur after the ingestion of the 
poison is set down by Lonsdale at from one to fifty-five minutes; but 
a case is reported in Guy's Hospital Reports, 1868, p. 259, observed by 
Dr. Hilton Fagge, in which the fatal result was put off for at least an 
hour and a quarter after the ingestion of hydrocyanic acid. After 
death the body often presents a livid surface, bloated countenance, 
fixed glassy eyes with dilated pupils, and clinched fingers; sometimes 
it offers nothing worthy of note except excessive rigidity, and the face 


CARDIAC DEPRESSANTS. 


429 


may be very pale. When opened, the odor of prussic acid is generally, 
but not always, emitted; the mucous membrane of the stomach is very 
commonly found much congested, and the dark or cherry-colored liquid 
blood usually everywhere tills up the veins. The heart is soft and 
flaccid. 

The treatment of poisoning by prussic acid is, unfortunately, as 
inefficient as it is simple. There is no known chemical or physiologi¬ 
cal antidote to it, the asserted antagonism of atropine having been dis¬ 
proved by the experiments of Keen ( Proc. Phil. Acad. Nat. Sci., 1869) 
and of Boehm and Knie. The stomach should, if possible, be emptied, 
and the hypodermic use of atropine as a respiratory stimulant might be 
tried; the inhalation of the vapors of ammonia, and the free exhibition 
of ammonia by the mouth and by injection into the veins, may be prac¬ 
tised. Artificial respiration has been found very successful by Preyer, 
and by Boehm and Knie, in animals when poisoned by small doses of 
prussic acid, and should always be assiduously practised. Next to it 
in importance is the use of the alternate cold and hot douche, about a 
half of a small bucketful of cold water and the same quantity of very 
hot (115° F.) water being dashed upon the chest in rapid succession. 

Administration.— The dose of the officinal dilute prussic acid is one 
to three drops. 

The Cyanide of Potassium (Potassii Cyanidum, U.S.) is prepared, 
according to the U.S. Pharmacopoeia, by heating together the ferro- 
cyanide of potassium and the carbonate of potassium. It occurs in 
white, amorphous, opaque masses, having the odor of prussic acid and 
a taste of similar character, but somewhat alkaline. It is deliquescent, 
and readily soluble in water. When the nitrate of silver is added to 
its solution, there falls a precipitate of the cyanide of silver, which is 
wholly soluble in ammonia. 

When cyanide of potassium is taken into the stomach, the acids 
there present convert it into prussic acid, and the same change probably 
occurs, although more slowly, even when the salt is injected directly into 
the blood-vessels. The physiological, therapeutical, and toxicological 
properties of this salt are similar to those of prussic acid.* Death, how¬ 
ever, does not occur so soon as when hydrocyanic acid has been taken, 
and insensibility is sometimes not manifested for several minutes. Five 
grains of the salt have caused death in several cases. The therapeutic 
dose is one-tenth to one-twelfth of a grain. 

The Cyanide of Silver (Argenti Cyanidum, U.S.) is a white insoluble 
powder, which is used solely for making prussic acid. 

Cyanogen Gas has been studied physiologically by Dr. B. Bunge 
(Arch. f. Exper. Path. u. Pharm., xii. 71). He finds that it kills by 
paralyzing the centres of respiration, but that it is less powerful and 

* Poisoning is stated to have occurred from the inhalation of the vapors of the cyanide; 
and, in photographers, from the absorption through the hands (Brit, and For. Med.-Chir. 
Rev., July, 1876, p. 231). 



430 


GENERAL REMEDIES. 


strong in its influence than is hydrocyanic acid, and causes only very 
feeble convulsions. 

VEGETABLE ACIDS. 

Although most of the officinal vegetable acids differ so much from 
the other substances considered in the present class as not to be poi¬ 
sonous except in enormous doses, and although they are never used to 
produce a profound impression upon the circulation, yet, since they 
have, or at least are believed to have, the power of lowering the force 
of the cardiac movements to some extent, and since they are so com¬ 
monly believed to have a tendency to depress animal temperature as to 
be usually spoken of as refrigerants , the present seems to me a fitting 
place for their consideration. In experiments made by W. H. Gas- 
kell ( Journ. of Physiol.., iii. 49), similar to those described in the article 
on digitalis (see p. 353), it was found that while alkalies contracted 
the arterioles of the frog, acids * caused a dilatation, probably by par¬ 
alyzing the muscular coats. Acids also diminished the activity and 
power of the frog’s heart. 

ACIDUM TARTARICUM—TARTARIC ACID. U.S. 

Tartaric acid occurs in large, hard, transparent, six-sided prisms, 
which are pyro-electric and phosphorescent when rubbed in the dark, 
and are nearly free from odor, but have a very sour taste. In the shops 
the acid is almost always kept in the form of powder. Tartaric acid 
is the acid of the grape, and occurs in grape-juice as a supertartrate 
of potassium. When the juice undergoes fermentation and alcohol is 
developed, the acid salt, not being soluble in the newly-formed men¬ 
struum, precipitates, collecting as a dark mass in the wine-casks, whence 
it is sent into commerce under the name of argol or tartar. Out of 
this substance the acid is manufactured by treating with lime, so as to 
form a tartrate of calcium, and precipitating this new compound in its 
watery solution by sulphuric acid, sulphate of calcium falling, tartaric 
acid remaining in solution. Tartaric acid is soluble in little more than 
half its weight of hot water and in less than its weight of cold water. 
It is distinguished from all other acids by forming a crystalline precipi¬ 
tate (bitartrate) when added to a neutral solution of potassa. 

Physiological Action.— When applied to a denuded surface, or in 
sufficient concentration to a mucous membrane, tartaric acid acts as 
a very decided irritant, and even upon the skin its saturated solution 
after a time causes redness and burning. 

When the drug is taken internally in sufficiently large doses, it acts 
as an irritant poison, causing violent oesophageal and gastric burning, 
vomiting, and, it may be, fatal gastro-enteritis. Upon animals it acts 

* Lactic acid appears to have been the only one used, and it does not appear certain that 
the results of experiments would be the same with all acids, as is stated in Gaskell’s generali¬ 
zation. 



CARDIAC DEPRESSANTS. 


431 


in large doses precisely as it does upon man. Thus, Mitscherlich states 
that three or four drachms suffice to kill a rabbit, the evident symptoms 
being great weakness of the heart’s action, difficult and slow breathing, 
and steadily-increasing pains, with slight convulsions before death. Ac¬ 
cording to Devergie, it requires nearly half an ounce to kill a dog when 
given by the stomach; but Pommer (quoted by Husemann) asserts 
that one gramme (15.34 grains) injected into the crural vein of a dog 
will produce death. 

Tartaric acid is never used internally by practitioners in such doses 
as to cause any of the symptoms above detailed, and it is evident that 
these symptoms throw little light upon its action in therapeutic doses, 
except to render it somewhat probable that the tendencies of the medi¬ 
cine are to lower cardiac action. This probability is increased very 
much by the experiments of Bobrick (quoted by Husemann, Die Pflan- 
zenstoffe, p. 561), who found that very large doses render the heart’s 
action weaker and slower. 

A great deal of interest to the therapeutist centres in the question 
as to what becomes of the acid in the system. Unfortunately, our 
knowledge in regard to this matter is far from complete; but the drug 
is probably partially burnt up in the body and partially eliminated by 
the kidneys. Wohler,* in his experiments, found it in the urine in the 
form of tartrate of calcium, while Buchheim* and Piotrowski* could 
find only a very small percentage of the ingested acid in the urine, and 
conclude that it is mostly destroyed in the body. Dr. Munch ( Archiv 
des Vereins fur Gemein. Arbeiten, 1863, p. 370) finds that when tartaric 
acid or citric acid is given it soon appears in the urine. Dr. H. Bence 
Jones ( Medical Times and Gazette , 1854, vol. ix. p. 408, and Lectures on 
Pathology and Therapeutics, London, 1867) has found that both citric 
acid and tartaric acid cause a pronounced increase in the acidity of the 
urine of persons taking them, and are apt also to give rise to the pres¬ 
ence of free uric acid in the excretion. Unfortunately, Dr. Jones did 
not attempt to determine whether the increased acidity was or was not 
due to the presence of the vegetable acid in the urine. 

Therapeutics. —Tartaric acid is rarely used in medicine, citric 
acid almost always being preferred. It may, however, be employed 
whenever it is desired to render the urine acid, in doses of ten to 
twenty grains; but it is less valuable than the acid of the lemon. 

Toxicology.— There are, I believe, but three fatal cases of tartaric 
acid poisoning on record : one reported by Devergie (Ann. d’Hygiene, 
1851, t. ii.); one by Professor Taylor (Principles and Practice of Medical 
Jurisprudence, London, 1873, p. 230), in which death took place nine 
days after the ingestion of an ounce of the poison dissolved in half a 
pint of water; and one (Aled. Press and Circular, Nov. 1880) in which 
a half-ounce of the acid was supposed to have been taken. The treat- 


* All these are quoted by Husemann, Die PJlanzenetoffe. I have not seen the originals. 



432 


GENERAL REMEDIES. 


ment of tartaric acid poisoning consists in the free exhibition of mag¬ 
nesia, of lime, of carbonate of potassium or of sodium, or of any article, 
such as soap, containing an alkali in a suitable shape, which may be at 
hand. The after-treatment is that of toxic gastro-enteritis. 

ACIDUM CITRICUM—CITRIC ACID. U.S. 

Citric acid is the acid of lemon- and lime-juice, from which it is ex¬ 
tracted by a process precisely similar to that employed in the manufac¬ 
ture of tartaric acid. It occurs in rhomboidal prisms, which are some¬ 
times very large, are nearly free from odor, but are possessed of a very 
sour, almost corrosive taste, which, when the acid is in sufficiently weak 
solution, is quite pleasant. Citric acid is soluble in three-fourths of its 
weight of cold water, in half its weight of boiling water, and in alcohol, 
and insoluble in ether. 

It is sometimes adulterated with tartaric acid, which may be readily 
detected by the addition of a strong neutral solution of carbonate of 
potassium to a strong solution of the suspected drug: if tartaric acid 
be present in any amount, a precipitate of the bitartrate will be formed. 

Physiological Action. —Citric acid in concentrated solution cer¬ 
tainly acts upon abraded surfaces and upon mucous membranes as an 
irritant, but, according to Mitscherlich, is less irritant than tartaric acid, 
since its concentrated solution has no action upon the sound skin. 

Ho case of poisoning by citric acid has occurred in man, that I am 
aware of, and Piotrowski (quoted by Husemann, Die Pflanzenstoffe, p. 
561) took, in six hours, thirty grammes, an hour later fifteen grammes, 
and an hour later thirty grammes, or nearly two ounces and a half 
in all, with the induction of no more serious symptom than vomiting. 
It is, therefore, somewhat doubtful whether citric acid is capable of 
causing death in man. This difference in action between it and tar¬ 
taric acid may depend upon the latter being so much the more irritant 
of the two: upon the urinary secretion their action is probably similar. 

Hugo Schulz states that citric acid is an active antiseptic, a five-per¬ 
cent. solution being sufficient to preserve small pieces of meat for two 
weeks; one part in a thousand was fatal to paramecia ( Deutsch . Med. 
Wochenschr., 1883, ix. 398). 

Therapeutics. —Citric acid is sometimes itself employed in medi¬ 
cine, hut is almost exclusively used in the form of Lemon-juice (Succus 
Limonis), which some, it is true, have thought to be dependent upon 
citrate of potassium for much of its virtue, but which contains, as 
shown by the analysis of Professor H. Bence Jones (Medical Times and 
Gazette , vol. ix., 1854), in every ounce twenty-six or twenty-seven grains 
of free citric acid, and not two grains of citrate of potassium. 

Lemon-juice has several very distinct uses in medicine, all of them 
resting upon clinical rather than physiological data. The chief and 
most important of these is in the cure and prevention of scurvy. During 
the disease it should be drunk freely in the form of lemonade, three or 


CARDIAC DEPRESSANTS. 


433 


four ounces of it being taken daily. As a prophylactic against the 
disease, lemon-juice is simply invaluable; but it is absolutely necessary 
that it be of good quality. It may be prepared for long voyages in 
one of two ways: first, boil the juice slightly, strain, allow to cool, pour 
into bottles up to their necks, fill the vacant space above with pure 
olive oil, cork tightly, and keep the bottle upright; second, add ten 
per cent, of brandy, and bottle as before ( Medical Times and Gazette , 
1854, p. 635). Citric acid is of some value in scurvy, but is incom¬ 
parably inferior to lemon-juice. In acute rheumatism , benefit may 
be derived from the free use of lemon-juice, as originally proposed by 
Dr. Rees, of London. One or two ounces of it may be given four or 
five times a day; but it is certainly less efficacious than the alkalies. 
In catarrhal jaundice , and in habitual torpor of the liver, the free ad¬ 
ministration of lemon-juice often aids in effecting a cure. In fevers, 
lemonade may be a very refreshing and useful refrigerant drink. 

Administration. —Lemon-juice, when it can be had, should always 
be preferred to citric acid; when only the latter is available, an artifi¬ 
cial lemon-juice may be made by dissolving in a pint of water an ounce 
of the acid with which four drops of the oil of lemon have been well 
rubbed up. 

ACETUM—VINEGAR. 

The physical properties of vinegar are too well known to need de¬ 
scription here. That best suited for medicinal use is in this country 
prepared from cider, and should have a trace of the taste of cider. 
It is sometimes adulterated with sulphuric acid, which may be at once 
detected by boiling with chloride of calcium, which precipitates any 
free sulphuric acid as sulphate of calcium, without affecting the small 
proportion of soluble sulphates existing in vinegar. Vinegar may be 
substituted for lemon-juice as the basis of an acidulous drink in fever 
when the lemon-juice is not to be had; but as an antiscorbutic it is 
certainly very much inferior to it, and has not, that I am aware of, 
been tried in rheumatism. 

Acetic Acid (Acidum Aceticum, U.S.) is a colorless liquid, having a 
pungent odor, free from empyreuma, and an intensely acid, corrosive 
taste. It contains thirty-six per cent, of the monohydrated acetic acid, 
and has a specific gravity of 1.047. Glacial or monohydrated acetic 
acid is not officinal. It is a colorless liquid, crystallizing at 34° F., and 
actively escharotic,—in a measure, no doubt, owing to its properties 
of dissolving gelatin and gelatinous tissue and of effecting a partial 
solution of albuminous matters. Dilute Acetic Acid (Acidusi Aceticum 
Dilutum) is officinally prepared by the addition of seven parts of water 
to one part of acetic acid, and should have the sp. gr. 1.006. Acidum 
Aceticum Glaciate, U.S., glacial or absolute acetic acid, is at 59° F. a 
crystalline solid. 

Dilute acetic acid, or its equivalent, vinegar, is a useful topical 
application in various superficial inflammations of the skin, such as 

28 


434 


GENERAL REMEDIES. 


“ sunburn," and in sprains. Applied to the skin, it acts as a powerful 
stimulant and astringent, causing contraction of the vessels and great 
whiteness. Diluted with two or three times its bulk of water, it is 
occasionally employed as an injection against seat-worms; but the infu¬ 
sion of quassia is preferable. 

The use of acetic acid as a caustic will be spoken of under the 
heading of Escharotics. 

Toxicology. —Acetic acid in any of its more concentrated forms is 
a corrosive poison, and death has been produced by it in at least one 
case (Orfila, Toxicologie , t. ii.). The symptoms resemble those caused 
by mineral acids, and the treatment is exactly similar,—neutralization 
by an alkali or its carbonate, or by some substance, such as soap, con¬ 
taining an alkali, and the meeting of indications as they arise. 

Oxalic Acid (Acidum Oxalicum) has been asserted ( Gaz. Hebdom., 
xxiii. 128) to be a valuable emmenagogue, but it is chiefly known to 
the profession as a poison. In 1874 (Gaz. Med., p. 92) Rabuteau an¬ 
nounced that in oxalic acid poisoning the nerves and muscles are not 
affected, and that therefore the acid acts upon the nerve-centres. This 
has been confirmed by the elaborate researches of Drs. R. Robert and 
B. Kiissner ( Virchow's Archie , lxxviii. 109), who find that it para¬ 
lyzes the respiratory, vaso-motor, and other motor spinal centres. It 
is also a cardiac poison, arresting the heart in systole (Les Nouveaux 
Remedes, 1886, ii. 290). The acid is eliminated by the kidneys. As a 
poison, oxalic acid figures in two forms: that of simple oxalic acid, and 
that of the acid oxalate of potassium, or salt of sorrel, or essential salt of 
lemons, as it is variously termed in common parlance. The symptoms 
produced are a hot acrid taste experienced during the swallowing, 
a burning in the gullet, soon extending to the stomach, intense abdom¬ 
inal pain, vomiting of highly acid, greenish, blackish-brown or bloody 
mucus (rarely of arterial blood), collapse, livid surface, cold skin, entire 
prostration of strength, small irregular pulse, stupor, unconsciousness, 
sometimes convulsions (cases, Guy's Hosp. Reports, 1838, iii.; Dublin 
Hosp. Reports, 1818, ii.), and finally death. In some cases the gastric 
symptoms are very prominent; in others they are nearly wanting, and 
the chief manifestations are collapse and such nervous symptoms as 
almost complete general paralysis, numbness, and finally stupor; in¬ 
deed, the patient may suddenly fall unconscious immediately after the 
ingestion of the poison (case, Guy's Hosp. Reports, 1874). According 
to Taylor, the smallest quantity which is known to have caused death 
is one drachm. An ounce usually proves fatal, but has been recovered 
from. After death the coats of the stomach are usually found softened 
and swollen, and sometimes perforated (case, Edinb. Med. Journ., vii., 
July, 1861). Dr. Rabuteau (Gaz. Med., 1874, p. 93) affirms that the 
blood is everywhere scarlet; but this is certainly not always the case 
(case, Taylor, Medical Jurisprudence, i. 224). According to Robert and 
Riissner, the urine during life contains some strongly reducing substance 


CARDIAC DEPRESSANTS. 


435 


of unknown nature, oxalate crystals in abundance, and usually albumen 
and tube-casts. A pathognomonic post-mortem lesion is, according to 
the same investigators, the incrustation of the urinary tubules with 
crystals of oxalates. In poisoning by oxalic acid, the immediate ad¬ 
ministration of an antidote is of the utmost importance. As the oxa¬ 
lates of potassium and of sodium are poisonous, neither potash nor soda 
is available; but fortunately lime or chalk is a perfect antidote to oxalic 
acid, forming the excessively insoluble oxalate of calcium. As time is 
a matter of so much importance, very often it is best simply to scrape 
the whitewash off a wall, a ceiling, a fence, or wherever it may be at 
hand, rub it up hastily with water, and administer it freely. The after- 
treatment is that of toxic gastro-enteritis. 


ORDER III.—NUTRIANTS. 


FAMILY I.-ASTKIYGEYTS. 

Astringents are those drugs which cause contraction of living 
tissues. That they do not act, as has been supposed, either by co¬ 
agulating albumen or by calling into action the muscular function, is 
demonstrated by the transitoriness of their effects, and by the fact 
that they influence tissues containing no muscular fibre. Every living 
soft tissue appears to possess a normal degree of condensation, which 
may be departed from on either hand: when this happens, in the one 
case the part is said to be relaxed, in the other to have its tonicity 
increased, or to be astringed. The action of astringents is always a 
local one ,— i.e ., produced not through the intervention of the nervous 
system, but by direct contact with the part affected. A pure astringent 
should be capable of doing nothing beyond inducing contraction; but 
in reality there is scarcely such a drug. All astringents are, when 
applied too freely, irritants; indeed, it is doubtful whether their thera¬ 
peutical property of astringency is not due to the exercise of a mild 
form of irritation. 

Our knowledge of the action of astringents upon blood-vessels is 
still very limited. The only published experiments are those of M. 
Rosenstein ( Rossbach’s Pharmakolog. Untersuchungen , Bd. ii. p. 80). He 
placed solutions of nitrate of silver, of acetate of lead, of sesquichloride 
of iron, and of tannic, gallic, and pyro-gallic acids upon the exposed 
mesenteric vessels of a curarized frog. The first three solutions con¬ 
tracted arterioles, venules, and capillaries, nitrate of silver being much 
the most powerful and the iron salt the weakest; the effect on the 
capillaries was the most permanent. The acids instead of contracting 
enlarged the vessels. This dilatation was not reflex, as it occurred 
after destruction of all the nerve-centres. It was probably due to the 
irritant action of the acid. 

The indications for the use of an astringent are very evident. 

In the first rank among such indications is the existence of relaxation. 
Local relaxation is almost always the result of previous over-excitement. 
Thus, a throat is relaxed after over-use, or after inflammation. 

Astringents are more efficient as local than as general remedies, but 
in cases of inflammation care must be taken to use them in such a way 
that they shall not act as irritants. Applied too soon or too vigorously, 
436 



ASTRIXGENTS. 


437 


they may do harm. These remarks are scarcely applicable to some of 
the mineral astringents, such as lead and nitrate of silver, which really 
appear to have sedative properties, and may with care be used advan¬ 
tageously in all stages of inflammation, whenever there is distention 
and relaxation of the blood-vessels, although the general action of the 
part be that of nutritive excitement. 

Closely allied to relaxation is over-secretion , and astringents are con¬ 
stantly used to check morbid discharges. Indeed, these discharges are 
often simply the result of relaxation. Thus, Asp has experimentally 
proved that division of the intestinal nerves and consequent paralysis 
and relaxation of the vessels are followed by free watery secretion. In 
such cases the indication for astringents is very plain. But when a 
morbid discharge represents a high degree of inflammation, the same 
care must be practised in the use of astringents as in treating other 
local inflammations. Especially is this true since free secretion is 
often nature’s method of relieving local inflammation. Thus, when 
abnormal alvine discharges are dependent upon intestinal relaxation, 
astringents are most valuable, but when they are dependent upon 
enteritis or colitis, astringents may do harm. 

If the morbid discharge by its profuseness endangers life, as in serous 
diarrhoea, astringents are urgently demanded. Very rarely, if ever, 
are these discharges other than paralytic in their origin; even, how¬ 
ever, if they be due to over-action, an astringent may be necessary to 
check their excessiveness. 

Another indication for the use of astringents is to check hemorrhage , 
and the same general reasoning is applicable to this as to the other 
indications. Hemorrhage dependent upon over-action demands other 
treatment than by astringents. Sometimes in these cases it is neces¬ 
sary, however, to check the hemorrhage at all hazards, and then astrin¬ 
gents may be used in conjunction with other measures, although they 
may be to some extent contra-indicated. Some of the astringents are 
employed locally to check hemorrhage due to traumatic or other rup¬ 
tures of vessels. In such cases the astringents are employed as styptics, 
and do not act so much by their astringency as by coagulating the 
albumen of the blood and thus forming a clot and mechanically arrest¬ 
ing the flow. 

Under certain circumstances there seems to be a general relaxation 
or loss of tone throughout the whole system, which may be best met 
by a consentaneous use of tonics and astringents. 

VEGETABLE ASTRINGENTS. 

The active principle of the vegetable astringents is tannic acid, and, 
as it is almost their sole therapeutic principle and represents them 
very closely, it seems proper first to consider it, and afterwards to point 
out any especial therapeutic virtues the crude drugs of the class may 
possess. 


438 


GENERAL REMEDIES. 


ACIDUM TANNICUM—TANNIC ACID. U.S. 

There are two kinds of tannic acid, the gallo- and the kino-tannic: 
of these the former yields, upon exposure to the air in a moist state, 
gallic acid , the latter a gelatinous, inert substance. They are further 
distinguished by the color of the precipitates which they yield with 
the persalts of iron; gallo-tannic acid producing a blue-black, kino- 
tannic a green-black color. 

The officinal tannic acid—the gallo-tannic acid—is obtained by 
treating powdered galls with washed ether, which on standing sepa¬ 
rates into two strata, the upper of which is ethereal and contains 
chiefly the coloring-matter and other impurities. The lower watery 
stratum contains the tannic acid, which is recovered by evaporation. 

Commercial tannic acid is a light, feathery, non-crystalline powder, 
of a yellowish-white color, a faint odor, and an astringent, somewhat 
bitter taste. When absolutely pure, it is colorless and free from odor 
or taste other than that of astringency. Its reaction is strongly acid, 
and it unites freely with both organic and inorganic bases. It is very 
freely soluble in water, even more so in glycerin, somewhat so in dilute 
alcohol, scarcely at all in absolute alcohol, and not at all in ether free 
from water. By a heat of from 108° C. to 215° C. it is changed into 
pyrogallic acid, which crystallizes in white, shining plates, of a bitter 
taste and neutral reaction. With salts of the alkaloids it produces a 
whitish precipitate, very soluble in acetic acid; with persalts of iron, 
a black (bluish or greenish) precipitate; with lime-water, a precipi¬ 
tate which is at first whitish, then gray, dingy greenish, and finally 
brownish; with gelatin or albumen, a whitish coagulum. All of these 
secondary products are tannates. Tannic acid also dissolves in con¬ 
centrated sulphuric acid, with the production of a black color. By 
jtrolonged exposure in solution to the air, or by the action of dilute 
sulphuric acid, it is converted into gallic acid. 

Physiological Action.— When applied locally to a part, tannic acid 
is a very powerful astringent, causing contraction, and, in the case of a 
mucous membrane, great dryness. Sometimes, when it is used very 
freely, its irritant influence seems to overcome its astringent action, 
and I have seen diarrhoea result from its administration. Several 
experimenters (Rosenstein, Untersuch. Pharmakolog. Institut Wurzburg, 
1875; Fikentscher, Inaug. Dissert., Erlangen, 1877) have denied that 
it causes contraction of the blood-vessels, because when they applied it 
to the exposed mesentery of a “ Cohnheim frog,” stasis of the blood, 
with dilatation of the vessels, not preceded by contraction, occurred. 
Daniels, however (Inaug. Dissert., Bonn, 1864), using rabbits, obtained 
different results, and Lewin has shown that the method of experimen¬ 
tation is faulty. Clinical experience abundantly proves that tannic acid 
applied to relaxed mucous membranes affects their whole substance. 

Tannic acid coagulates albumen with so much avidity that it has been 


ASTRINGENTS. 


439 


supposed to be incapable of absorption, but the very elaborate investi¬ 
gations of Dr. Lewin cast much doubt upon the older views on this 
subject ( Virchow's Archiv, lxxxi. 74). Thrown rapidly into the blood, 
it undoubtedly causes a fatal thrombosis; but Lewin asserts that when 
it is injected slowly and in moderate quantities the resulting tannate 
of albumen is held in solution by the alkaline carbonates of the blood. 
He has also discovered that while tannin, in five-per-cent, solution, pre¬ 
cipitates peptones out of watery solution, it is powerless in the presence 
of hydrochloric acid. Assuming the correctness of the investigation of 
Dr. Lewin, it is plain that tannic acid, when put in the stomach in small 
doses, must to some extent be absorbed unchanged. Dr. Lewin also 
asserts that it is, at least in part, eliminated unaltered, as he has fre¬ 
quently recovered it from the urine. At the same time it seems very 
probable that most of the tannic acid is converted into gallic acid, 
either in the stomach before absorption, or subsequently in the system, 
since in the viscera of a rabbit poisoned with it, Schroff ( Die Pflanzen- 
stoffe, Husemann, p. 1005) found only gallic acid; and according to 
Clarus ( Ibid, .) the greater part of ingested tannic acid can be recovered 
from the stools as tannate of albumen or as gallic acid. The recent 
researches of Stockman {Brit. Med. Journ ., Dec. 4, 1887) afford a pos¬ 
sible reconciliation of the results of Lewin with those of the older ob¬ 
servers. Stockman finds that when tannic acid is given to the lower 
animals only a trace of it appears in the blood, while gallic acid can be 
obtained in abundance from the urine, with occasionally a smajl amount 
of tannic acid. If, however, tannate of sodium be given, tannic acid 
appears in abundance in the urine, with a little gallic acid. The expla¬ 
nation offered by Stockman of this is probably correct,—namely, that 
tannic acid is usually converted in the stomach into a tannate of albu¬ 
men, which is dissolved with great difficulty in the intestinal juices, so 
that time is afforded for the conversion of the tannic into gallic acid, 
whereas an alkaline tannate is absorbed at once and rapidly eliminated 
unchanged. When tannic acid is exhibited in medicine it is in all proba¬ 
bility almost entirely converted into gallic acid. Wohler and Frerichs 
have also found gallic acid with pyro-gallic acid in the urine after the 
exhibition of tannic acid. Whether it acts chiefly as tannic or as 
gallic acid, it seems after absorption to exert marked astringent powers. 
Lewin has shown that in frogs poisoned with it the muscles are short¬ 
ened and narrowed, and when loaded stretch less and recover their origi¬ 
nal length more nearly than do normal muscles. Kuchenmeister {Arch. 
Physiolog. Heilk ., 1851, 493) and Hennig {Arch. Pharmak ., Feb. 1853) 
state that in poisoned cats the spleen is notably diminished in size and 
increased in firmness; and Lewin has found in rabbits that tannic acid 
causes primary arrest of the urinary secretion, followed by a marked 
increase of the flow. 

Therapeutics. —As tannic acid undergoes in the system partial con¬ 
version into gallic acid, the latter is to be preferred to it when the part 


440 


GENERAL REMEDIES. 


to be acted on can be reached only through the circulation. Asa local 
application, tannic acid is much more powerful than gallic acid. Lo¬ 
cally applied, it may be used to overcome relaxation , as in spongy gums, 
mercurial sore mouth, hemorrhoids, chronic sore throat. To check hemor¬ 
rhage it may be used whenever the source of the flow can be reached 
directly, as in epistaxis, hcematemesis , hemorrhage from the bowels^ etc. 
To arrest excessive secretion it may be employed locally in leucorrhcea, 
diarrhoea, old abscesses, chronic ulcers , excessive perspiration, osmidrosis, 
and various diseases of the skin. It is also often very useful for the 
purpose of hardening parts exposed to friction, as in cases of sore 
nipples and tender feet. 

Toxicology. —Tannic acid can scarcely be called poisonous; although 
Eollett reports the case of a young girl in whom a very large quantity 
of it induced severe gastric and abdominal pains, with obstinate vomit¬ 
ing and constipation, fever and general malaise. Both Schroff and Judell 
assert that eighty grains of it cause no symptoms of importance in 
the rabbit. 

As an antidote it is useful in tartar emetic poisoning, forming an 
insoluble tannate of antimony. It is also the best chemical antidote 
for the poisonous alkaloids; but, as the compounds it makes with them 
are slowly dissolved by the fluids of the alimentary canal, it must always 
be followed by emetics and cathartics. 

Administration.— When given to act on the stomach, as in hsema- 
temesis, tannic acid should be in powder (ten to twenty grains). When 
the bowel is to be influenced, as in diarrhoea, the drug should be admin¬ 
istered in pill (three to five grains), so that, if possible, it may pass the 
pylorus undissolved. For local use a solution in glycerin may be em¬ 
ployed, or the officinal ointment ( TJnguentum Acidi Tannici, U.S., 1 to 9), 
or the troches ( Trochisci Acidi Tannici , U.S., 1 grain each). 

ACIDUM GALLICUM—GALLIC ACID. U.S. 

Gallic acid is a white, powdery substance, in fine acicular prisms, 
soluble in one hundred parts of cold water, in three parts of boiling 
water, and freely soluble in alcohol and in ether. Its taste is acidulous 
and astringent. 

According to the officinal method, gallic acid is prepared by the 
exposure of moistened powdered nutgalls in a warm place for a month. 
A species of fermentation, with the development of a peculiar fungus, 
is said to occur, during which oxygen is absorbed, carbonic acid is 
evolved, and glucose and gallic acid are produced. M. Sacc ( Chem. News, 
July 24, 1871) has, however, denied this, affirming that the change is 
simply one of hydration, tannic acid being an anhydride of gallic acid. 
Tannic acid also may be rapidly converted into gallic acid by the action 
of dilute sulphuric acid. 

Gallic acid produces with salts of the alkaloids whitish precipitates, 
with persalts of iron a bluish precipitate, with lime-water a whitish 


ASTRINGENTS. 


441 


precipitate, changing to blue, and then to violet or purplish,—all of 
these precipitates being gallates. It does not coagulate gelatin or albu¬ 
men, and dissolves in concentrated sulphuric acid, with production of a 
deep-red color. It has the power of reducing silver from its solution 
slowly in the cold, instantaneously if warmed. As an astringent it is 
similar to, but much less powerful than, tannic acid. It escapes from 
the body through the kidneys. 

Therapeutic Action. —Gallic acid is not nearly so efficient as tannic 
acid when applied locally, but, because it does not coagulate albumen, 
should always be preferred when the part is to be reached through the 
medium of the circulation. It is useful as an astringent in hcemoptysis, 
hcematuria, colliquative sweats, etc. It has been recommended in bron- 
chorrhoea and in the profuse expectoration of chronic phthisis. In my 
hands, however, it has completely failed in the latter affections. In 
certain forms of Bright's disease, when there was no abnormally large 
secretion of highly albuminous urine, I have found it to lessen very 
materially the excretion of albumen. 

Administration.— Gallic acid may be given in powder, or sometimes 
in pill form. The dose of it is from ten to thirty grains, repeated as 
often as may be necessary. An ointment (Unguentum Acidi Gallici, 1 
to 9) is officinal. 

GALLA—GALLS. U.S. 

Galls are vegetable excrescences which are produced by the depo¬ 
sition of the ova of insects. They occur on almost all kinds of plants, 
even on fungi, but the officinal gall is developed on the Quercus infec- 
toria by the act of the fly Cynips ( Diplolepis ) tinctoria. There are in 
commerce two varieties of galls, derived chiefly from the Levant. The 
blue or green galls are globular, solid bodies, from the size of a pea to 
that of a hickory-nut, externally smooth, or more commonly marked 
with large tubercles. They are the young galls which have been 
gathered before the ova of the fly have hatched, or before the cater¬ 
pillar has eaten out the interior of its birthplace. The white galls are 
large, light, hollow bodies, with a hole, through which the Cynips has 
escaped after having fed upon the interior during its whole larval life. 
They contain but little tannic acid, and are of comparatively little 
value. 

Therapeutics. —The sole value of galls is as the source of tannic 
acid. As galls, they should not be used in medicine: but the United 
States Pharmacopoeia recognizes a tincture (Tinctura Gallce, 1 to 5), and 
an ointment ( Unguentum Gallce, 1 to 9). 

CATECHU—CATECHU. U.S. 

An extract of the wood of an East Indian tree,—the Acacia Catechu. 
It occurs in masses of various shapes, or in small fragments, of 
a dull reddish-brown color, and having a bitterish, astringent, and, 
after a time, sweetish taste. It contains kino-tannic and catechuic 


442 


GENERAL REMEDIES. 


acids. Pale catechu , or gambir , which is officinal in the British but 
not in the United States Pharmacopoeia, occurs in small cubes, about 
an inch in diameter, lighter than water, pale-yellowish within, deep- 
yellowish or reddish-brown externally. Catechu is a powerful astrin¬ 
gent, which may be used externally, or for diarrhoea , in the dose of 
twenty to thirty grains. 

The U.S. Pharmacopoeia recognizes a compound tincture {Tinctura 
Catechu Composita, Catechu 12, Cinnamon 8, to 100), of which the dose 
is one to three fluidrachms, and troches (Trochisci Catechu , 1 grain 
each). 

KINO-KINO. U.S. 

The inspissated juice of Pterocarpus marsupium and of other plants. 
It occurs in small, irregular, angular, shining, reddish, brittle frag¬ 
ments, of a bitterish, highly astringent, and, after a time, sweetish taste. 
There are four varieties,—the East India, West India, Botany Bay, and 
African. Of these, the first is common, the second rare, and the last 
two are never seen in our market. Kino contains kino-tannic acid, 
and in its therapeutic powers is almost identical with catechu. The 
dose is twenty to thirty grains. A tincture ( Tinctura Kino , 1 to 10) is 
officinal. Dose, one fluidrachm. 

HAEM ATOXYLON—HAEM ATOXYLON. U.S. 

The heart-wood of Ilsematoxylon Campechianum, or logwood-tree, 
a native of Central America,—a dense, heavy wood, of a deep reddish- 
brown color, containing, besides kino-tannic acid, a crystalline principle, 
Hccmatin or Hcematoxylin , which when pure is yellow, but readily yields 
red or purple dyes. Hsematoxylon is a mild efficient astringent, valued 
on account of its sweetish taste. It is readily taken by children, but 
is sometimes objected to on account of the staining of the diapers by 
the blood-red stools which it produces. The following formula offei’8 
an efficient and elegant remedy for diarrhoeas of relaxation; the pro¬ 
portions may be varied to suit individual cases: R Ext. hsematoxyli, 5h; 
Acid, sulph. aromat., f^iii; Tinct. opii camph., fgiss; Syrupi zingiberis, 
q. s. ad fgvi. M.—Dose, a tablespoonful, properly diluted. The extract 
( Extractum Hcematoxyli ) is officinal; dose, ten to thirty grains. 

KRAMERIA—RHATANY. U.S. 

The root of Ivrameria triandra, a native shrub of Peru. This woody 
root, as it occurs in our markets, varies from one-fourth inch to one 
inch in diameter, and from half a foot to three feet in length. The 
readily separable bark is of a deep-reddish color. The internal wood}' 
portion is of a lighter hue, although decidedly reddish. The bark con¬ 
tains a much larger percentage of the active principle, kino-tannic acid, 
than the wood. Rhatany is a powerful astringent, similar in virtue to 
kino and catechu, but is never administered in powder. The United 
States Pharmacopoeia recognizes an extract (Extr actum Kramerice), dose, 


ASTRINGENTS. 


443 


grs. v-x; a tincture (Tinctura Kram.erice, 1 gr. to 1 C.c.) ; and a fluid ex¬ 
tract (Extractum Kramerice Fluidum ), dose, twenty drops. 

Quercus alba, U.S., and Quercus tinctoria are the inner barks of 
the trees whose names they bear,—the white and the black oak respec¬ 
tively. The latter is a rough, yellowish-brown bark, which is used in 
dyeing, under the name of quercitron. On account of its imparting 
readily its color, it is rarely, if ever, employed in medicine. White-oak 
bark also stains, but not nearly so deeply as does black-oak bark, and, 
containing largely of gallo-tannic acid, is used as a means of making 
cheap astringent infusions for baths, vaginal washes, etc., also in powder 
for poultices. 

Rosa Gallica, U.S., is the dried petals of the half-opened flowers 
of the hundred-leaved rose. They are of a deep-red color, of a pleasant 
scarcely astringent taste, and contain a small percentage of gallo-tannic 
acid, red coloring-matter, and a trace of volatile oil. Sulphuric acid 
changes their infusions or tinctures to a bright-red color. They are 
almost destitute of therapeutic virtues, but their preparations, except 
the fluid extract, are used as elegant vehicles. The U.S. Pharmacopoeia 
recognizes a fluid extract (Extractum Rosce Fluidum ), a honey (Mel Rosce, 
1 to 12.5), a confection (Confectio Rosce), and a syrup (Syrupus Rosce, 
fluid extract, 1 to 10). 

Rosa Centifolia, U.S., or Pale Rose , contains no tannic acid, but a 
volatile oil, and is used simply on account of its pleasant odor: out of 
it are prepared rose water (Aqua Rosce, U.S.) and the very elegant, bland 
emollient ointment, cold cream ( Unguentum Aquae Rosce, U.S.). 

The rhizome of Geranium maculatum Linn., an herbal plant, which 
grows abundantly in open woods in the middle United States, and may 
be recognized by its light-purplish petals, slender pointed sepals, and 
five-parted leaves, is officinal under the name of Geranium. It occui*s 
in pieces from one to three inches long, one-quarter to one-half inch in 
thickness, wrinkled, contorted, tuberculated, often fibrillated, brownish 
externally, grayish internally. The taste is a nearly pure astringent 
one. It contains largely of gallic and tannic acids, and is a somewhat 
popular astringent. It may be boiled in milk for children needing a 
mild astringent. Dose, grs. xx-xxx. 

Rhus Glabra. U.S.—The fruit or berries of the sumach contain 
a very large percentage of tannic and malic acids. They are not used 
internally, but their fluid extract (Extractum Rhois Glabrae Fluidum, 
U.S.) affords a very superior gargle in anginose affections. It may be 
diluted with from two to four parts of water, and chlorate of potassium 
added to saturation. 


444 


GENERAL REMEDIES. 


MINERAL ASTRINGENTS. 

ALUMEN—ALUM. U.S. 

Formerly the double salt of alumina and potash constituted the 
ordinary alum as well as the officinal drug. Ammonia as a secondary 
product in the manufacture of coal-gas has become so cheap, however, 
that it is now used very largely instead of potash, although the potash 
alum is alone recognized in our officinal standard. The two salts are 
identical in physical and medical qualities, but when the ammonia alum 
is triturated with lime the odor of ammonia is at once evolved. Alum 
occurs in octahedral colorless crystals, which are often aggregated into 
large masses. Its taste is astringent, acidulous, and sweetish. It is 
soluble in about fifteen times its weight of cold and in about three- 
fourths its weight of boiling water. It is slightly efflorescent, and 
when heated a little beyond 112° F. parts with its water of crystal¬ 
lization, and is converted into a white powder, which is officinal as 
Alumen Exsiccatum , or Dried Alum. The alkalies and their carbonates, 
lime, magnesia and its carbonate, tartrate of potassium, and acetate of 
lead are incompatible with alum. 

Physiological Action.— As alum, even in very dilute solutions, co¬ 
agulates albumen, it would appear as though it could not be absorbed. 
Since, however, both Drs. Geo. B. Wood and A. Stille assert, on what 
authority I do not know, that alumina can be detected in the urine of 
persons taking it, it or its derivatives must find a way into the blood. 
What changes it undergoes in the alimentary canal, or in what form it 
enters the blood, is not known. 

Applied to a tissue, it acts as a very powerful astringent and irri¬ 
tant. Orfila found that in dogs one or two ounces of it simply induce 
violent vomiting and purging, while in Mitscherlich’s experiments two 
drachms of it produced in rabbits fatal gastritis, evidently on account 
of their inability to vomit. 

In man, large doses internally produce symptoms of violent gastric 
irritation. One ounce and five drachms of the burnt alum caused 
death in a man in eight hours (17 Union Medicate , No. 64, 1873). 

Therapeutics.— Alum may be used locally to serve all the purposes 
of a very active astringent. It has been employed very frequently 
with success as a styptic to arrest hemorrhage; and, applied by the 
atomization of its saturated solution, I have found it of signal service 
in hcemoptysis and in bronchorrhoea. It also frequently enters into the 
composition of gargles for sore throat; but this practice is to be repro¬ 
bated, since alum acts very destructively on the teeth. In colliquative 
sweats, sponging at bedtime with alum-water, or, still better, the taking 
of an alum-water bath, will often materially aid in restoring the lost 
tone to the skin. In chronic ulcers with exuberant spongy granulations, 
and in certain conditions of conjunctivitis , alum curd is often applied 


ASTRINGENTS. 


445 


with benefit. When it is desired to exert an astringent action upon 
the internal organs, alum is not nearly so useful as other members of 
the class. 

Owing to its irritant properties, alum when given in sufficient amount 
acts as a mechanical emetic, and may be used as an adjuvant to the 
sulphate of zinc or of copper in narcotic poisoning. Originally intro¬ 
duced by Dr. C. D. Meigs, it is believed to be of service in membranous 
croup not only by its emetic action, but also by modifying the mucous 
membranes with which it comes in contact in its passage down and up. 

So long ago as the last century, Dr. Grashius, of Holland, com¬ 
mended alum in colica pictonum, and, although for a long time its value 
was not recognized, abundant confirmative testimony has recently been 
brought forward. Since it is a soluble sulphate, it is of course a chem¬ 
ical antidote to any lead salt which may be in the alimentary canal. It 
is, however, of service when there is no lead in the primae vise, and 
must act in some way as yet unknown. It has, indeed, been used with 
asserted success in other neuroses of the alimentary canal,—in gas- 
tralgia and in intestinal neuralgia. Dr. Aldredge even commends it in 
habitual constipation. Burnt alum — i.e., alum which has had its water 
of crystallization driven off by heat—is used as a very mild escharotic 
for the destruction of exuberant granulations in ulcers. 

Administration. —As an astringent, the dose of alum is from ten to 
twenty grains ; as an emetic, a teaspoonful of the powder for a child, 
a tablespoonful for an adult, in syrup, repeated in fifteen minutes; in 
colica pictonum , twenty to forty grains every three or four hours, 
combined with morphine. Alum curd may be made by dissolving two 
drachms in a pint of milk, and straining, or by rubbing the alum with 
white of egg. 

Aluminii Sulphas—Sulphate of Aluminium (Al 2 O s 3SO s -f-18HO— 
3S0 4 ,Al 2 -j-18H0), U.S.—This salt, which occurs as a white powder, or 
in lamellated cakes, or in a crystalline cake, is used externally as a 
powerful astringent and antiseptic. Its solution has also been employed 
by injection for the preservation of cadavers. 

PLUMBUM-LEAD. (Pb.) U.S. 

When a soluble salt of lead is applied to a part in not too concen¬ 
trated solution, it acts as an astringent and sedative. Owing to the 
contraction of the vessels which is induced, the tissue becomes blanched, 
and any inflammatory action which may be present is remarkably 
affected. When in concentrated solution, the mildest preparations of 
lead are capable of acting as irritants, increasing or even originating 
inflammation. When the salts of lead are taken internally in thera¬ 
peutic doses, no decided symptoms are generally induced, except a 
diminution of the secretions, especially of those of the alimentary 
canal. Sometimes, when full therapeutic doses are exhibited, a slight 
lowering of the frequency and force of the pulse (see Laidlaw’s Obser- 


446 


GENERAL REMEDIES. 


vations, quoted by Stille, Therapeutics , second edition, vol. i. p. 177) is 
said to result, but I have never witnessed this. The insoluble prepara¬ 
tions of lead act similarly to but less decidedly than the soluble; yet it 
is doubtful whether they can under any circumstances become irritant. 

Toxicology.— The salt of lead with which intentional or accidental 
acute poisoning is most frequently induced is the acetate.* The first 
result of a toxic dose of this is in most cases a persistent sweet, some¬ 
what metallic taste; this in a few minutes is followed by vomiting, 
which may or may not be preceded by nausea. The matters vomited 
are often milky-white, from the presence of chloride of lead. A severe 
burning persistent pain in the abdomen now comes on, and is accom¬ 
panied with a craving for drink. There may be obstinate constipation, 
or diarrhoea may ensue: in either case the stools are generally black 
from the sulphuret of lead. In certain cases a state of collapse is de¬ 
veloped ; the pulse falls to forty or fifty per minute, the voice is lost, 
the face is deadly pale, the lips are livid, and syncope seems imminent. 
In other instances the nervous symptoms may predominate, or they 
may accompany those of disordered circulation: cramps in the calves 
of the legs, severe neuralgic pains in the extremities, paralysis and 
anaesthesia, vertigo, stupor, may any or all of them be present. In 
fatal cases, coma, with or without convulsions, finally develops. A dis¬ 
tinctive mark of lead-poisoning, which sometimes is present very early, 
is the blue line upon the gums. After death inflammation of the ali¬ 
mentary mucous membrane is sometimes, but not always, found. 

The fatal dose of sugar of lead is between one and two ounces; the 
subacetate of lead is even more poisonous, and the nitrate acts as a vio¬ 
lent irritant. The carbonate appears to be incapable of causing acute 
poisoning. 

The treatment of acute lead-poisoning consists in the evacuation of 
the stomach, if necessary, the exhibition of the sulphate of sodium or 
of magnesium, and the meeting of the indications as they arise. The 
Epsom and Glauber’s salts act as chemical antidotes, by precipitating 
the insoluble sulphate of lead, and also, if in excess, empty the bowel 
of the compound formed. To allay the gastro-intestinal irritation, 
albuminous drinks should be given and opium freely exhibited. 

Of all forms of poisoning, chronic lead-poisoning is the most 
common. It is almost always accidental, and occurs most frequently 
among those whose occupation exposes them to daily contact with 
some compound of the metal, manufacturers of white lead, painters, 
glaziers, and similar artisans furnishing the greater number of victims. 
It is seen, however, in persons of all conditions of life, for although 
neither food nor drink is often purposely adulterated with it, yet it is 
frequently introduced into the system accidentally along with those 


* According to Husemann (Handbuch cler Toxicolngie), the poudre de succession, so 
famous during the reign of Louis XIV., was composed chiefly of acetate of lead. 



ASTRINGENTS. 


447 


necessities. Lead pipes are habitually used for the conveyance of 
water, and when the water contains salts of lime, even in minute pro¬ 
portion, no evil results, because through the decomposition which 
ensues insoluble coatings are deposited on the inside of the pipes.* 
When the water is pure, no such reactions occurring, the lead is slowly 
dissolved in the form of a carbonate, and poisoning may result. Poi¬ 
soning has also frequently resulted from the use of cosmetics and hair- 
dyes, from cooking bread with painted wood (Le Progres Med., 1877, 
349), from imperfectly-burnt pottery ( Schmidt's Jahrb., Bd. cxliv. p. 
279; Phila. Med. Tunes , vol. iv. pp. 241, 483), from habitually biting 
silk thread which rascally manufacturers often load with lead to give 
weight to it,-j* and in other curious wayk. 

The most ordinary form of chronic lead-poisoning is that in which 
colic is the first decided symptom. After some days of malaise and 
wretchedness, or sometimes very suddenly, the victim is taken with 
abdominal colicky pains, which increase in intensity until they become 
very severe. They are constant, with occasional exacerbations, are 
sometimes dull, sometimes sharp, are generally described as twisting, 
and seem to centre around the umbilicus. There is very often repeated 
retching and vomiting. The walls of the abdomen are retracted, rigid, 
knotted; the bowels are obstinately costive; the tongue is contracted 
and whitish, the appetite gone, and the thirst sometimes excessive. 
Xeuralgic pains in the thorax and in the extremities are of frequent 
occurrence. In some cases the conjunctiva is distinctly icterodo. 

These symptoms usually abate after a time, but are very apt to recur 
with increasing severity, especially among those who are habitually 
exposed to the cause. In one of these repeated attacks severe cerebral 
symptoms may come on suddenly in some such cases after some days 
of headache; delirium, either mild or maniacal, or stupor, appears as 
the chief manifestation, but epileptiform convulsions are more common, 
constituting the condition known as enceplialopathia saturnina, or sat¬ 
urnine cerebritis. The convulsions are often very violent, and end in 
coma, in which death usually takes place; yet recovery may occur 
after the most severe symptoms (case, Charite-Annalen , ix. 159). The 
chronic nervous symptoms of lead-poisoning may be developed after 
the first attack of colic, or they may occur without marked abdominal 
disturbance. The most common of them is the local paralysis known 
as “ drop-wrist .” This is a complete palsy of the extensor muscles of 
the forearm, which allows the hand to drop forward. It is often as¬ 
sociated with complete or partial ana3sthesia of the part affected, or, 


* For an elaborate article on the chemical relation of water to lead, see Schmidt’s Jahr- 
biicher, cxliv. 279. 

j- Chronic lead-poisoning is produced much more frequently by insoluble than by soluble 
compounds of lead, and it is probable that any saturnine preparation may cause it. Thus, 
chromate of lead has killed numbers of people. See Medical Neics , ii. 1887, also Therap. 
Gaz., iv. 



448 


GENERAL REMEDIES. 


in some cases, of the still unparalyzed shoulders. Strabismus is some¬ 
times present in lead-palsy, due to the paralysis of the external recti. 

Among the rarer forms of nervous disturbance induced by lead may 
be mentioned—amaurosis from atrophy of the optic nerve, the atrophy 
being probably the result of an optic neuritis (see Phila. Med. Times , 
iv. 241; also Berliner Klin. Wochenschr ., 1884, 370), hemiplegia and 
hemiansesthesia, and violent and intractable chorea.* I have seen 
several cases in which the symptoms resembled those of an acute 
poliomyelitis, with rapid wasting of all the muscles of the arms and 
shoulders, the legs also being affected. In one instance the bladder 
and rectum were paralyzed, but the patient, long at the point of death, 
finally recovered. In some victims violent neuralgic pains are the 
chief outcome of lead-poisoning. In a case in which my diagnosis was 
confirmed by finding lead in the water habitually drunk and in the 
urine of the patient, the symptoms were intense general pruritus, with 
violent neuralgic pains shooting through the rectum and the urethra 
coming on at night and producing an insomnia which appeared to be 
unconquerable. In a remarkable paper, Dr. J. J. Putnam, of Boston 
( Trans. Assoc. American Physicians, ii.), details a large number of cases 
in which the symptoms did not conform with any of the ordinary 
recognized types of lead-poisoning, although the metal was found in 
the urine. These cases were characterized by such symptoms as the 
following: 1. Trembling of hands; sense of coldness and numbness 
in toes; lancinating pains in legs; fatigue on exertion. 2. Marked 
progressive spastic paraplegia, with myosis and pupillary reactions; 
ataxia and some atrophy of hands. 3. Progressive weakness and stiff¬ 
ness in legs, with diffused and almost universal pains; marked tremor. 
4. Temporary pain in chest, with slight dyspnoea; progressive numbness, 
heaviness, and weakness in legs. 5. Numbness in feet and legs, with 
impairment of strength; tremor of hands and tongue; some wasting 
of small muscles of hands; temporary retention of urine. 

In some cases of lead-poisoning the kidneys are fatally involved, 
although temporary albuminuria may occur without serious implication 
of the kidneys. On the other hand, fatal nephritis may exist when 
there is no albumen in the urine (Dr. Lancereaux, Trans. Internat. 
Med. Congress , 1881, ii. 191). A persistent low specific gravity of the 
urine in a saturnine patient is of very serious import. Geppert (Zeit- 
schrift f. Klin. Med., v. 161) confirms the observation, previously made 
by Olivier, that in temporary plumbic albuminuria many isolated kid¬ 
ney epithelial cells may often be found in the urinary sediments; and 
it is evident that a persistence of this condition must end in chronic 
renal disease. After death, which may be induced by uraemia, the 

* For discussion of details of these peculiar conditions, see Beau, Arch. Gin., 1848; 
Manouvriez, Arch, de Physiol. Norm, et Patholog., 1870, p. 411 ; 1876, p. 762; A. De Cours, 
Be l ’Hemiansesthesia saturnine, Paris, 1875; Proust, Progrls Mid., 1879, vii. 546; Debove, 



ASTRINGENTS. 


449 


kidneys are found contracted, granular, with excessive development of 
the fibrous tissue (followed by contraction) and great thickening of the 
walls of the blood-vessels: these changes are identical with those of 
contracted kidney produced by gouty and other irritant poisons. As 
Ellenberger and Hofmeister have shown that the lead is chiefly elimi¬ 
nated by the kidneys, the frequency of plumbic nephritis is easily 
explained ; but it is not readily perceived why it is so frequently asso¬ 
ciated with an arthralgia whose course and lesions closely simulate 
those of chronic gout. Garrod (1859), Dickinson, Lancereaux, Rosen- 
stein, Leyden ( Zeitschrift f. Klin. Med., 1884, p. 881), and other authors 
have reported so many cases of this association of renal and gouty 
manifestations that it can scarcely be doubted that the plumbism is 
the cause of the gouty symptoms, and not simply a complication of 
gout.* 

According to Dr. E. Levy ( Schmidt's Jahrb., Bd. clii. p. 250), acute 
asthma is rarely produced by the inhalation of the dust of white lead, 
and chronic saturnine asthma is sometimes seen in feeble, narrow- 
chested people. The epileptiform convulsions produced by lead are in 
some cases secondary to chronic nephritis, but in other instances are 
due directly to the action of the lead (see paper of Dr. Rosenstein, 
Archiv f. Path. Anat., 1867, Bd. xxxix. p. 4). Upon pregnant women 
the influence of the poison is very deleterious, and Dr. Constantine 
Paul ( Archives Gen., 1860, vol. xv. p. 513) has shown that it very 
commonly produces the early death of the foetus. 

As any of these obscure manifestations of lead-poisoning may 
exist, and even prove fatal, without a distinct history of other more 
characteristic phenomena, great care is sometimes necessary to avoid 
being misled, and not rarely the true nature of saturnine epilepsy 
or of satuniine albuminuria is overlooked. Hence the importance of 
the blue line upon the gums where they join the teeth, which is very 
common in persons suffering from lead-poisoning. It is said to be the 
result of a formation in the walls of the capillaries of the sulphide 
of lead. As was first pointed out by Dr. J. J. Putnam ( Trans. Amer. 
Neurol. Assoc., 1883), chronic lead-poisoning may exist without this blue 
line upon the gums. Under such circumstances, if the symptoms be 
obscure the diagnosis can be established only through a chemical ex¬ 
amination of the urine.f The practitioner should see that the urine 
which is to be sent to the chemist for examination be slightly acidi¬ 
fied, that directly after passing it be put in flint glass bottles, and that 


* Consult Deutsch. Med. Woehenschri/t, 1883, pp. 185, 351; 1884, p. 129; also Dr. Paul 
Musehold, Die Bleivergiftung, Berlin, 1883. I have myself seen one case. 

The analyses made in the cases of Dr. Putnam, so far as can be judged from the recorded 
evidence, are not absolutely above suspicion. For an elaborate discussion, see Leading Article 
in Therap. Gaz., Dec. 1887. 

j- For an elaborate discussion of the methods of detecting lead in urine, see Therap. Gaz. 
iii. 813, also iv. 92. 


29 



450 


GENERAL REMEDIES. 


it be at least a quart in quantity. The question as to whether lead 
can be for a length of time in the system and continually appear in 
the urine without injury to health cannot yet be positively answered. 

I have seen in painters a paralysis of one arm and one-sided wrist¬ 
drop, apparently the result of a local action of the poison; and Dr. 
Manouvriez ( Recherches cliniques sur VIntoxication saturnine, Paris, 
1874) has recorded similar observations. (See also La France Med,., 
1882, i. 892.) 

In those cases of lead-poisoning which pursue a slow course to death, 
the paralysis involves after a time the extensors of the lower as well as 
of the upper extremities, epileptic paroxysms occur at intervals, rack¬ 
ing pains shoot through the limbs, points of cutaneous anaesthesia 
appear, and often albuminuria aids in producing the fatal issue. Gradu¬ 
ally the patient becomes more and more cachectic, general oedema and 
the whitened skin betray the increasing anaemia, the paralysis extends 
from muscle to muscle, locomotion becomes impossible, and, if a con¬ 
vulsion or other accident do not close the scene, death at last takes 
place from loss of power in the respiratory muscles. M. Malassez has 
found that in the anaemia of lead-poisoning the red globules are not 
only diminished in number but also increased in size (. Archives de 
Physiologie, 1874, p. 50). 

After death lead has been frequently detected in the tissues. Heubel 
found most of it in the bones, and less in the muscular than in the 
nervous system ( Virchow und Hirsch's Jahrbucher , 1871, vol. i. p. 316). 
Professor Chatin ( Comptes-Rendus Soc. de Biol., 1862, iv. 84) obtained 
from the cervical spinal cord three in one hundred and fifty parts. 
In the studies of Ellenberger and Y. Hofmeister (Arch. f. Wissen. und 
Prakt. Thierheilk., x. 216) the liver and kidneys were found to contain 
the most lead, after them the bones, then the nerve-centres, and finally 
the flesh. 

The electro-muscular contractility is affected very early in lead¬ 
poisoning, and may be lost before the voluntary movements. It is 
stated by M. Kaymond that the short extensor of the thumb preserves 
its function when all the other extensor muscles are paralyzed. The 
paralyzed muscles are finally exceedingly wasted, and their structure 
may be so totally destroyed that scarcely a single striated fibre can be 
found. The nerve-trunks are lessened in size, in many of their tubules 
the medulla has been replaced by fatty granules, and in some cases 
every trace of the tubules has disappeared and the nerve been reduced 
to a fibrous cord. According to the researches of M. Degerine ( Comptes- 
Rendus Soc. de Biol., 1880), the first appearance of change in a nerve- 
trunk consists in the myeline becoming broken up into blocks, and the 
nature of the change is a commingling of a parenchymatous and an 
interstitial neuritis, which both Degerine and Yulpian have traced 
upwards as far as the anterior spinal roots. Lancereaux (Gaz. Med. 
de Paris, 1862, 1871), Westphal (Arch. f. Psych., iv. 776), Friedliinder 


ASTRINGENTS. 


451 


( Virchow's Arch., lxxv. 24), and others, may be cited as having found 
very distinct peripheral lesions in lead-poisoning. Whether these 
lesions begin in the nerve or in the muscles cannot be considered 
as determined. Birdsall (N. Y. Med. Record , March, 1882) reported a 
case of what he believed to be a plumbic myositis, and Gourbault (Le 
Progres Med., 1880) describes primary alteration in the nerves, similar 
to those seen after section, as occurring in poisoned guinea-pigs, while 
MM. Debove and Reaut ( Le Progres Med., 1876, 151) describe the first 
changes as resembling those of subacute myositis, and Friedliinder em¬ 
phatically asserts that lessening in the size of the muscular fibres and 
multiplication of the muscular nuclei precede the nerve-degeneration. 
On the other hand, Vulpian (. Maladies du Systeme Nerveux, 1879), 
Monakow (Arch. f. Psychiat. und Nervenkr., x. 495), Oeller ( Festschrift 
dem Aerztl.Verein d. Munchen, 1883), and a number of other observers 
(for references, see Arch. f. Psychiat. und Nervenkr., xvi. 477) have 
noticed structural changes (poliomyelitis, capillary hemorrhages, etc.) 
in the spinal cord of men dead of plumbism; while Popow ( Virchow's 
Archiv, Bd. xciii. p. 351) found that when guinea-pigs were rapidly 
poisoned (six to eight days) with lead there was produced a central 
myelitis, which first affected the large cells of the gray matter, and 
afterwards involved the white matter, the peripheral nerve-filaments 
remaining normal. There is, however, no real contradiction, as Popow 
believes, between his observations and those of Gourbault, for the latter 
(Arch, de Physiol. Norm, et Path., 1873) poisoned his animals veiy slowly 
(six months), and it is not improbable that the rapidity of the poisoning 
should have influence upon the seat of the lesion. As already stated, 
the symptoms of plumbism may exactly simulate those of general 
poliomyelitis, and Degerine has found degeneration of the motor cells. 
The evidence at present indicates that lead is capable of producing a 
peripheral neuritis, and also a centric poliomyelitis, which may or 
may not coexist in an individual case; the probabilities being in favor 
of a peculiar peripheral neuritis, as the primary lesion of ordinary 
plumbic wrist-drop (see paper by Professor Schultze, Arch. f. Psychiat. 
u. Nervenkr., 1885, xvi. 809). Hemorrhages into the nerve-centres 
sometimes occur (Le Progres Med., xii. 827). 

Rudolf Maier ( Virchow's Archiv, Bd. xc. p. 480) has found that the 
intestinal mucous membranes and walls suffer, in animals poisoned 
with lead, changes similar in nature to those already detailed as occur¬ 
ring in the kidney, and has also shown that there is wide-spread de¬ 
generation of the arterioles. It would appear that lead is an almost 
universal poison to the higher tissues, and that at present we are 
unable to say why in any individual case one part rather than another 
is attacked. 

The excretion of lead with the gall is very active, but it is probable 
that it chiefly escapes from the body with the urine. The elimina¬ 
tion seems to be capricious, and much affected by iodide of potassium 


452 


GENERAL REMEDIES. 


(Melsens, Ann. Phys. et Chim., xxvi.; Pouchet, Arch, de Physiol ., xii. 
74) and by other influences.* 

The treatment of chronic lead-poisoning evidently arranges itself 
under three indications: 1st, to prevent the ingestion of more of the 
poison; 2d, to aid in the elimination of that in the system; 3d, to re¬ 
lieve symptoms and restore lost functions. In lead-colic both of the 
last two indications are met by purgatives, to which opium should be 
added to relieve pain. It is often necessary to use the most powerful 
drastics, such as croton oil; but senna, salts, and other of the milder 
cathartics should always be tried first. Alum , it is asserted, acts in 
some unknown way as a specific in lead-colic, and from twenty to sixty 
grains of it may be given four or five times a day; but my own expe¬ 
rience is not favorable to its use. In the more chronic forms of lead- 
poisoning, to fulfil the second indication baths of sulphuret of potassium 
should be employed, and iodide of potassium be administered internally. 
The bath should be given (Dr. A. Eulenburg, Deutsch. Arch. f. Klin. 
Med., Bd. iii. p. 506) in a wooden tub, two or three times a week, and 
should contain six or seven ounces of the salt. The patient, during the 
half-hour of his continuance in it, should be from time to time well 
rubbed with a coarse towel. On coming out he is to be thoroughly 
washed with warm soap-suds. The dose of the iodide should be from 
fifteen to twenty grains, administered after meals, in dilute solution. 
A case is reported in the London Lancet , 1876, ii. 53, in which galvanic 
baths were used successfully, the patient being placed in the bath and 
the positive pole of a twenty-eight-ceil battery applied to the nape of 
the neck, the negative to the feet. When severe cerebral symptoms 
arise, treatment is of little avail, and should be largely expectant.-}* 
In cases of lead-poisoning in which the symptoms resemble those of 
acute poliomyelitis I have used ascending doses of strychnine with 
most extraordinary results, rapidly-deepening paralysis being almost 
at once controlled. It is essential that the strychnine be pushed to 
the point of systemic intolerance. It is best to administer it by the 
mouth, or if used hypodermically it should be given at least twice a 
day. It may possibly prove of value in other acute forms of lead-palsy. 


* Lead has been found in the urine of man or of the lower animals by Orfila, Lewald 
(Ausscheidung der Arzneimittel, Breslau, 1861), Gusserow (Virchow’s Archiv, Bd. xxi.), An- 
nuschat (Arch. f. Exper. Path, and Pharm., x. 260), and Oettinger ( Wiener Med. Wochen- 
schrift, 1858); also in my clinical service at the University Hospital. 

f It seems doubtful whether the sulphur baths really aid elimination, but I have certainly 
seen good follow their use. It has been denied that the iodide acts; but cases are reported in 
which lead was not in the urine before, and was after the administration of the drug (see 
Brit. Med. Journ., 1880, ii. 1034). Moreover, Dr. John Marshall (Therap. Gaz., iv. 97) has 
shown by actual experiment that potassium iodide in solution has an action on the insoluble 
carbonate and phosphate of lead, with the formation of a soluble lead compound,—double 
iodide of lead and potassium; and therefore, if lead taken into the system be deposited in 
the tissues as insoluble carbonate or phosphate, these latter compounds, on the administra¬ 
tion of potassium iodide, will be decomposed, with the production of a soluble lead compound, 
and consequently a more rapid elimination of the lead will occur. 



ASTRINGENTS. 


453 


The local use of electricity is exceedingly important to restore the 
lost function of nerve and muscle. When the faradic current elicits 
a response, it should always be employed; but in some cases (Meyer’s 
Electricity , New York, 1869, p. 284) the continued current retains its 
power after the induced has lost all its influence. The rule is always 
to apply that current which causes contraction; if both fail, the con¬ 
tinued current should be used, the poles being reversed at intervals 
of four or five seconds. The electrical seances should be tri-weekly, 
each lasting about fifteen minutes, and they should be persevered in for 
months. I have seen great improvement in a case which for the first 
four months yielded no results; indeed, long after voluntary movement 
had in great measure returned, no form of electricity would cause con¬ 
traction of the affected muscles. 

Physiological Action. —The symptoms of acute lead-poisoning are 
chiefly due to its local irritant action, but those of chronic poisoning 
are of wider significance. How the lead is absorbed to produce them 
is uncertain,—probably as an albuminate. All the compounds of lead 
and albumen as yet discovered by the chemist are, however, precipi¬ 
tated by alkaline carbonates, and cannot therefore exist in the blood. 

The symptoms of chronic lead-intoxication to be accounted for are 
the colic, the anaemia and wasting, the palsies, and the rare cases of cere¬ 
bral symptoms or of kidney-degeneration. In explaining them we are 
chiefly indebted to the researches of Dr. Ernest Harnack (Archiv f. 
Experim. Path. u. Pharm., 1878), who employed the compound of lead 
and ethyl, first discovered by Loewig. When this is injected into 
animals in large quantities it causes a rapidly fatal train of symptoms 
evidently due to the action of the compound itself. When, however, 
the introduction into the system has been slow, a chronic poisoning is 
produced by the lead set free in the blood and tissues. 

Under these circumstances a constant symptom, in both dogs and 
rabbits, is diarrhoea, due to a violently increased peristalsis, with, in the 
dog, occasional attacks of colic. As both the diarrhoea and the exces¬ 
sive peristalsis are arrested by atropia, they are probably the result of 
an action upon the intestinal ganglia. The colic in man is probably 
due to the excitement becoming so intense as to cause spasmodic con¬ 
traction of the muscular coat of the intestine and consequent arrest of 
peristalsis, obliteration of the intestinal lumen, and constipation. If 
such be the case, large doses of belladonna should at once give relief. 
Dr. Harnack found that in dogs the lead ethyl produces violent ex¬ 
citement, with chorea, convulsions, etc., evidently due to an exciting or 
irritant action upon the cerebrum, and believes that this explains the 
saturnine cerebral cases sometimes seen in man. 

The chief symptom of the poisoning in frogs was a progressive 
palsy of muscular origin. The muscle became exhausted on repeated 
galvanization much more rapidly than is normal, and after death was 
incapable of undergoing complete post-mortem rigidity. The peripheral 


454 


GENERAL REMEDIES. 


nerves appeared to have escaped entirely. The heart-muscle shared 
the fate of the voluntary muscles. The muscular action of the poison 
was excessively pronounced in rabbits, but was feeble in dogs and cats. 
Different results have, however, been arrived at by Dr. H. von Wyss 
( Virchow's Arch., Bd. xcii.), who found that the loss of reflex activity, 
etc., in the frog was not prevented by tying an artery so as to protect 
the leg from the poison, and that the protected muscle lost its power 
of responding to electrical stimulation just as fast as did the one reached 
by the lead. He concludes, therefore, that the paralysis is of centric 
origin. Curci is stated to have proved that lead exerts an irritant 
influence upon the peripheral branches and ganglionic centres of the 
pneumogastric ( Gaz. Hebdom., 1883, 552; from Gazzetta degli Ospitali, 
March, 1883). 

The pulse in lead-colic is usually very hard and tense. Sphygmo- 
graphic studies made of it by August Frank ( Deutsch . Arch. Klin. Med., 
xvi. 422) and Ernest Bardenhewer (Berlin. Klin. Wochenschr., 1877, 126) 
have been thought to indicate a condition of general arterial spasm, 
and have given rise to the very improbable theory that the colic is 
caused by intestinal anaemia from vaso-motor contraction. Barden¬ 
hewer found that hypodermic injections of pilocarpine relieve simul¬ 
taneously the pulse and the colic, precisely as Harnack discovered that 
atropine does. Harnack, however, found that in rabbits and dogs the 
lead ethyl has no action upon the circulation except by direct influence 
on the cardiac muscle, and that it does not produce vaso-motor spasm. 
He is probably correct in believing that the pulse of lead-colic is due to 
an overfulness of the blood-vessels produced by an expulsion of the 
blood from the intestines by the severe spasm of their coats. Accord¬ 
ing to the researches of Ellenberger and Hofmeister, in the sheep toxic 
doses of lead greatly depress the elimination of urea. 

The following preparations of lead are officinal in the United States 
Pharmacopoeia: 

PLUMBI OXIDUM—OXIDE OF LEAD. U.S. 

Litharge, which is prepared by blowing air through melted lead, 
occurs in small yellowish or orange-colored scales, which are insoluble 
in all ordinary menstrua. It is rarely used as a desiccant astringent 
powder for ulcers, but its chief employment in medicine is as the basis 
of the following preparations: 

Kmplastrum Plumbi, or Lead Plaster, is made by boiling litharge, 
olive oil, and water together. Glycerin is set free, and the oleo-mar- 
garate of lead is formed. Lead plaster occurs in grayish, cylindrical 
rolls, which become adhesive at the temperature of the body, and, spread 
upon kid, is sometimes used as a protective to parts exposed to pressure, 
or to superficial ulcers or abrasions. Emplastrum Resince, or Resin 
Plaster, or adhesive or sticking plaster, is made by incorporating resin 
with lead plaster, and, spread upon linen, is much used in surgery for 


ASTRINGENTS. 


455 


mechanical purposes. Emplastrum Saponis, or Soap Plaster , is made by 
the addition of soap to lead plaster. It is employed chiefly as a pro¬ 
tective. 

PLUMBI ACETAS—ACETATE OF LEAD. TJ.S. 

Sugar of lead is made by the action of acetic acid upon litharge, or 
upon sheets of lead exposed to the air. It occurs in transparent, acicu- 
lar, often aggregated crystals, of a sweet, styptic taste. It is soluble 
in water, to which it usually imparts a slight milkiness. From its solu¬ 
tion it is precipitated black by sulphuretted hydrogen, white by soluble 
carbonates, chlorides, and sulphates, and bright yellow by iodide of 
potassium. It is also incompatible with the mucilage of slippery elm, 
but scarcely so with that of flaxseed or of pith of sassafras. 

Therapeutics. —A solution of acetate of lead is used very largely 
in acute external inflammations as a sedative and astringent lotion. 
Although chemically incompatible, it is frequently combined very ad¬ 
vantageously in these cases with opium. As a too concentrated solution 
acts as an irritant, the strength for use on the skin should not exceed 
ten grains to the ounce. In diseases of the eye it is condemned by 
oculists, because when there is any abrasion of the cornea it is very 
prone to deposit an opaque film. 

Internally, acetate of lead has been employed very largely in hemor¬ 
rhage : indeed, Professor George B. Wood commends it as the most 
valuable of all astringents in hcemoptysis (Therapeutics , vol. i. p. 158). 
I think it is now, however, rarely given for this purpose. Its chief use 
at present is in diarrhoea. On account of its sedative properties, when 
the purging is attended with inflammation it is the most serviceable 
of all the astringents; and, owing to the promptness of its action, it is 
also very valuable in cases with profuse serous discharges. In dysentery 
it is very useful whenever the discharges have become copious. The 
dose is from two to five grains, always in pill, repeated pro re nata. 

Liquor Plumbi Subacetatis.— The Solution of Subacetate of Lead , 
or Goulard's Extract , as it is sometimes called, is a colorless, limpid 
liquid, of a sweetish, astringent taste. It is made by boiling litharge 
in a solution of acetate of lead, and has an alkaline reaction. When 
exposed to the air, it rapidly absorbs carbonic acid and deposits 
carbonate of lead, the neutral acetate being left in solution. In its 
action upon the human organism, Goulard’s extract resembles very 
closely the simple acetate of lead; but it is never used internally. 
Externally, it is a favorite application in cases of sprains or bruises , as 
well as in superficial inflammation. For this purpose it requires dilu¬ 
tion, and from a fluidounce to four fluidounces of it may be added to a 
pint of water. When used upon a raw surface, the strength should 
not be so great. A sedative poultice, which is very highly recom¬ 
mended by some physicians in the early stages of inflammation, may 
be made by saturating crumbs of stale bread with Goulard’s extract 


456 


GENERAL REMEDIES. 


diluted with four to six times its bulk of water. This poultice must 
he applied cold. The officinal Liquor Plumbi Subacetatis Dilutus , or 
Diluted Solution of Subacetate of Lead, is of the strength of three 
parts in a hundred. It is too weak to be of much value. 

Plumbi Carbonas, U.S., or Carbonate of Lead , is a heavy, white, 
tasteless powder, insoluble in distilled water, but slightly soluble in water 
containing carbonic acid. It is used solely as an external sedative ap¬ 
plication. Bubbed up with linseed oil, it constitutes white-lead paint, 
and in this form, or in that of the ointment ( Unguentum Plumbi Carbo- 
natis, U.S.), it is a most efficient dressing for fresh burns. Care must be 
taken in its use, however, when a large surface is involved, as lead-colic 
has been caused by its absorption. 

Plumbi Nitras, U.S., or Nitrate of Lead , occurs in white, nearly 
opaque, octahedral, very heavy crystals, soluble in alcohol and in seven 
and a half parts of cold water. It is used chiefly as a disinfectant. 
Dissolved in water, it forms Ledoyen's Disinfectant Solution. It acts by 
decomposing the sulphuretted hydrogen, itself being converted into a 
sulphuret of lead. It is said to attack actively the soldering of pipes 
(.Report on Hygiene , TJ. S. Navy, 1879). Its chemical reactions are 
similar to those of the acetate, from which it may be distinguished by 
a mixture of it and sulphuric acid striking a red color with morphine. 
Nitrate of lead is frequently used in onychia maligna. The dead part 
of the nail should be cut away, and the powdered nitrate thickly 
sprinkled over the surface; after a few days the slough separates, 
leaving a clean surface, upon which the new nail usually soon forms. 
Sometimes more than one application of the remedy is required. 

BISMUTHUM—BISMUTH. 

The metal bismuth is never used in medicine in its simple or metallic 
form. 

BISMUTHI SUBCARBONAS—SUBCARBONATE OF BISMUTH. U.S. 

(Bi0 3 C0 2 ,H0—2Bi 2 0 3 C0 3 ,H 2 0.) 

A white or yellowish-white powder, tasteless and odorless, totally 
insoluble in water, soluble with effervescence in dilute nitric acid. 
Bismuthi Subnitras, or Subnitrate of Bismuth, U.S., is a heavy white 
powder, odorless, with a faint acid taste, and a decidedly acid reaction 
when applied to moistened litmus-paper, insoluble in water, soluble 
without effervescence in nitric acid. The officinal processes for the 
preparation of these salts are too complicated for discussion in a work 
like the present, the object of the various stages being to get rid of 
arsenic, which contaminates all the bismuth ores of Europe. Of late 
years the South American bismuth has been introduced into commerce, 
and, as it contains no arsenic, commercial bismuth preparations are 
no longer contaminated. 


ASTRINGENTS. 


457 


Physiological Action. —The actions of the subnitrate and of the 
subcarbonate of bismuth are so exactly similar that they can practically 
be considered as one thing. Orfila and other of the older observers 
attributed to bismuth violent irritant properties, stating that severe 
symptoms and even death sometimes followed its ingestion. In a large 
proportion, if not all, of these cases the results were due not to the 
bismuth, but to the arsenic with which it was contaminated. Never¬ 
theless, the soluble preparations of bismuth are actively toxic agents (see 
Bismutiii Citras), and the fact that the subcarbonate and subnitrate 
of bismuth when pure have practically no irritant power, but are feebly 
astringent sedatives, is due to the difficulty of their absorption. Taken 
into the alimentary canal they act simply as local agents, and can be 
administered without injury in very large quantities. It has been 
shown by the experiments of Theodore Kocher ( Volkmann's Klinischer 
Vortrage, No. 224) that even the insoluble bismuth preparations have 
active antiseptic properties and are serviceable in the treatment of 
wounds. This use of them has led to the discovery that, when ap¬ 
plied in very large quantities to extensive wounded surfaces, they are 
capable of yielding so much bismuth to absorption as to produce a 
poisoning, which is characterized by acute stomatitis with a peculiar 
black discoloration of the mucous membrane, usually beginning upon 
the borders of the teeth, but spreading over the whole mouth, followed 
by an intestinal catarrh with pain and diarrhoea, and in severe cases with 
desquamative nephritis, as shown by albuminous urine and epithelial 
tube-casts. (For cases, see Kocher, loc. cit., also Professor Petersen, 
Deutsches Med. Wochenschr., June 20, 1883.) 

It has been denied that the subcarbonate and subnitrate of bismuth 
are dissolved in the alimentary canal; but we now know that they are 
very slowly absorbed and eliminated. Harnack affirms ( Arzneimittel- 
lehre, 1883, p. 383) that the metal has been found by Orfila in the liver, 
spleen, and urine, and by Lewald in the milk. MM. Bergeret and 
Mayen^on ( Journal de VAnatomie, 1873, p. 242) state that when the 
subnitrate of bismuth is administered the metal can always be de¬ 
tected, after a few hours, in the urine. They have also discovered it 
in the serous exudation of dropsy, and have proved that when a few 
grains of the salt mentioned are given to rabbits, in from twenty to 
thirty minutes it can be found in the urine, kidneys, spleen, blood, and 
muscles, and even eight days after the administration can be detected 
in all the tissues. Five days after the exhibition of a gramme of the 
subnitrate to a man, they found traces of the metal in the liver and 
kidneys; but the analysis of the body of a woman dead sixty-two 
days after the ingestion of two grammes yielded only negative results. 
Professor E. S. Wood also has detected bismuth in the urine four weeks 
after its last exhibition (Trans. Amer. Neurolog. Assoc., 1883, p. 23). 

Therapeutics.— The preparations of bismuth are of great service 
in various forms of irritation of the alimentary canal. They are very 


458 


GENERAL REMEDIES. 


useful to allay vomiting dependent upon gastric irritation. In simple 
neuralgic gastric pain following eating, especially when occurring in 
feeble, badly-nourished subjects, bismuth is often of great service; and 
even in carcinoma it may palliate by alleviating pain and vomiting. In 
pyrosis it is sometimes successful. In simple diarrhoea of irritation, and 
in the chronic diarrhoea of camps, the bismuth preparations are often 
very efficient; and in the chronic bowel complaints of children, especially 
as seen in the summer season, given with pepsin, they are almost in¬ 
valuable. Bismuth is a very valuable topical remedy in the treatment 
of mucous inflammations and of ulcers to which it can be applied 
directly. Thus, in the beginning of a gonorrhoea , the injeetion every 
two hours of a mixture containing twenty grains of bismuth to the 
ounce usually brings immediate relief; in a similar way it may be em¬ 
ployed in leucorrhoea and in acute coryza. In Germany it has been to 
some extent employed as a surgical dressing. 

Administration. —In order to get the best attainable results from 
the use of subnitrate of bismuth it is necessary to vary the dose and 
method of administration. In stomachic affections from five to fifteen 
grains may be given preferably when the stomach is empty, in order 
that the bismuth may be distributed as closely as possible over the 
gastric mucous membrane. In intestinal diseases from fifteen grains 
to a drachm may be exhibited from one to two hours after meals at 
a time when the gastric contents are escaping through the pylorus. 
Children bear proportionately very large doses: thus, five to ten grains 
may be given to a two-year-old infant. 

Bismuthi Citras. U.S.—The insoluble citrate of bismuth is not used 
in medicine, but has been introduced into the Pharmacopoeia for the 
production of the soluble Bisinuthi et Ammonii Citras , U.S. According 
to Feder-Meyer ( Inaug. Diss., Wurzburg, 1879), the ammonio-citrate 
of bismuth causes in rabbits violent tremblings with diarrhoea, accom¬ 
panied after large doses by disturbance of the sensibility and of co¬ 
ordination, tetanic cramps, altered respiration (in the beginning accel¬ 
erated and superficial, afterwards becoming slow), continual lowering 
of the blood-pressure, and death. The same observer noticed in chronic 
poisoning similar symptoms with albuminous urine and after death fatty 
degeneration of the liver, heart, and renal secreting structure. Similar 
observations were made by Mory, who {Inaug. Diss., Berne, 1883) states 
that the death in mammals is the result of cardiac paralysis, and that 
in the advanced stages of chronic poisoning, when the blood-pressure is 
very low, it is not elevated by stimulation of the splanchnic nerves nor 
by asphyxia. W. Steinfeld {Arch. f. Exper. Path. u. Pliarm., xx. 41) 
has obtained in the frog from the administration of ammonio-citrate and 
ammonio-tartrate of bismuth peculiar tremblings of the voluntary 
muscles with prolongation of contraction upon stimulation with the 
galvanic current, and slowing of the heart’s beat, also after sufficient 


ASTRINGENTS. 


459 


doses paralysis of nerves and muscles; effects which he attributes not 
to the bismuth, but to the acids of the preparations. He states that the 
proper symptoms produced by the metal only appear after some hours, 
and consist of motor excitement with reflex cries which are due to 
irritation of the medulla oblongata. In acutely poisoned mammals he 
noticed vomiting and purging, convulsions with loss of power, slowing 
of the pulse, and sinking of the blood-pressure, believed by him to be all 
of centric origin. In chronic poisoning there was loss of certainty 
of movement with cardiac depression followed by increasing paralysis, 
usually ending in death without convulsions. In his studies upon ab¬ 
sorption and elimination he found that the ammonio-citrates and am- 
monio-tartrates are quickly eliminated through the kidneys, so that, 
as a rule, after from ten to fifteen hours they can no longer be found in 
the blood, tissues, or urine. 

Therapeutics. —I know of no serious poisoning in man by the am- 
monio-citrate of bismuth, but it is undoubtedly capable of acting as a 
violent gastro-intestinal irritant. It has none of the peculiar properties 
which grow out of the insolubility of the subnitrate, but is more as¬ 
tringent, and has been employed to some extent in doses of five grains 
in chronic diarrhoea and in the acute diarrhoeas of relaxation. It should 
be administered in a dilute watery solution, repeated every three to six 
hours pro re nata. 


CERII OXALAS. U.S. 

Oxalate of cerium is a white powder, insoluble in water, alcohol, and 
ether, but soluble in sulphuric acid. It has been employed in medi¬ 
cine quite largely for the relief of vomiting , especially when dependent 
upon pregnancy or other forms of uterine disturbance. Its action on the 
economy ha3 not yet been made out, but it may be tried with some hope 
of success in cases of nervous or dyspeptic vomiting. The dose is one 
to three grains, in pill, three or four times a day. 

ZINCUM-ZINC. 

Zinci Sulphas. — Sulphate of Zinc. U.S. — White Vitriol occurs in 
irregular white masses, the pure sulphate of zinc in minute, transparent, 
four-sided, prismatic crystals, which effloresce slightly in dry air, and 
are soluble in two and a half times their weight of cold, and much less 
of hot, water; insoluble in alcohol. The taste is styptic and peculiar. 

Therapeutics. —Sulphate of zinc is in weak solution a stimulant 
astringent, in concentrated form an active irritant. Taken in doses 
of thirty grains it acts as a prompt, efficient mechanical emetic. In 
smaller doses, of two grains, it is sometimes given in pills as a stimu¬ 
lant astringent in chronic diarrhoea with ulceration. 

Toxicology. —Sulphate of zinc in large doses acts as an irritant 
poison, producing violent vomiting, colicky pains, diarrhoea, prostration, 
etc. The symptoms which it causes are almost identical with those 


460 


GENERAL REMEDIES. 


produced by the corresponding salt of copper. Alkalies and their car¬ 
bonates are the chemical antidotes to it, producing insoluble precipi¬ 
tates. Eggs and milk should also be exhibited, and the symptoms 
treated as they arise. Chronic zinc-poisoning, if it really exists at all, 
is very rare, and the metal seems to be used with impunity in cooking- 
utensils. Dr. Schlockow, however, affirms (. Deutsches Med. Wochen- 
schrift , 1879, 208) that zinc-smelters rarely live to be over forty-five,— 
dying sometimes with catarrh of the bronchial or alimentary mucous 
membranes, or, in other cases, of a peculiar nervous affection, which 
commences with burning superficial pains, exalted sensibility, and reflex 
activity in the legs, and afterwards puts on still more clearly the feat¬ 
ures of myelitis. 

Zinci Oxidum Yenale. — Commercial oxide of zinc is a snow-white 
powder, obtained by burning the metal in the air. It should be used 
only in pharmacy. The pure oxide (Zinci Oxidum, U.S.) is made by 
heating the carbonate until the water and acid are driven off. It is a 
yellowish-white powder, insoluble in water, but soluble without effer¬ 
vescence in dilute acids. 

Therapeutics. —Oxide of zinc is used externally as a mildly astrin¬ 
gent, slightly stimulant, and desiccant application in skin diseases and 
to ulcers. When given- continuously in small doses it is believed to 
act as a tonic and alterative upon the nervous system. It has also been 
commended as an astringent in chronic catarrhal diarrhoea of adults 
and infants, and has been largely used in epilepsy and in chorea. The 
dose is one to five grains. The ointment (TJnguentum Zinci Oxidi , U.S. 
—one part to four of benzoinated lard) is especially useful in chronic 
eczema. 

Zinci Carbonas Pr^ecipitatus. U.S.— Precipitated carbonate of zinc 
is intended to replace the old impure native carbonate, calamine. It is 
made by precipitating the sulphate of zinc by the carbonate of sodium. 
It is a white powder, closely resembling in its medical properties the 
oxide of zinc. 

Zinci Acetas. U.S.— Acetate of zinc is made by the action of acetic 
acid upon the commercial oxide of zinc. It occurs in white, micaceous 
crystals, which effloresce in a dry atmosphere and are very soluble in 
water. The taste is astringent and metallic. The acetate of zinc re¬ 
sembles in its physiological and therapeutic qualities the sulphate, but 
is probably somewhat less active. It is chiefly used in collyria (one to 
two grains to one fluidounce), and as an injection (one to twenty grains 
to one fluidounce) in gonorrhoea. 

Cadmium is employed in medicine to some slight extent in the form 
of its sulphate , which is stated to resemble closely the sulphate of zinc 


ASTRINGENTS. 


461 


in its therapeutic properties. It has been especially used as an astrin¬ 
gent stimulant in collyria, made by dissolving half a grain to four grains 
in an ounce of rose-water. Strangely enough, some physicians who 
have employed it state that it has ten times the strength of the zinc 
salt, others that it is about equivalent to it. 

CUPRUM-COPPER. 

CUPRI SULPHAS—SULPHATE OF COPPER. U.S. 

The sulphate of copper occurs in blue, transparent, slightly efflores¬ 
cent, rhomboidal prisms, or their fragments. It dissolves in four parts 
of cold and in two of boiling water, but is insoluble in alcohol. With 
ammonia its solution precipitates a bluish-white hydrated protoxide of 
copper, which redissolves when an excess of the alkali is added, forming 
a rich deep-blue solution. 

Physiological Action. —In very dilute solution the sulphate of 
copper acts locally as a stimulant and mild astringent; in a more con¬ 
centrated form it is an irritant; in powder it is a very mild caustic, 
which is scarcely capable of destroying sound tissue. Taken inter¬ 
nally in very small amounts and continuously, it is thought to have 
a corroborant influence upon the nervous system. Professor Falck 
(Deutsche Klinik , xi., 1859) has found that the sulphate of copper 
acts upon pigeons, dogs, rabbits, etc., as an irritant neurotic poison, 
producing great depression of temperature, with progressive general 
paresis, ending in death, apparently from failure of respiration. When 
the copper salt was given hypodermically, vomiting was not produced; 
although when it was exhibited by the mouth, emesis was very violent 
and persistent. In doses of five to fifteen grains it acts upon man as 
an irritating emetic, and in larger amounts is an irritant poison. 

Therapeutics. —The chief internal use of sulphate of copper is as 
a mechanical emetic. As it is more irritating than sulphate of zinc, it 
acts more rapidly and in smaller dose. For the same reason, however, 
it is not so safe as the white vitriol, and cannot be repeated so freely 
when its action fails. 

As a stimulant and astringent it is occasionally administered, in pill 
form, in chronic diarrhoea with ulceration. In small repeated doses it 
has been used in various nervous affections with doubtful advantage. 

The chief value of the so-called “ blue stone ” is as an external appli¬ 
cation. When applied in solid form to ulcers, it destroys flabby granu¬ 
lations and exerts a powerful excitant influence. Its solution acts more 
feebly, and is sometimes employed as a dressing for indolent ulcers , but 
more frequently as a stimulant and alterant to mucous membranes, as 
in granular conjunctivitis. 

Toxicology.— The symptoms of acute copper-poisoning generally 
come on in about a quarter of an hour after the ingestion of the poison, 
but may be postponed for from one to two hours. They consist of vio¬ 
lent vomiting and purging, accompanied by very severe colicky pains. 


462 


GENERAL REMEDIES. 


The matters vomited are greenish or bluish, the stools glairy, mucous, 
and at times bloody. There is a very strong taste of copper in the 
mouth, and often constant expectoration; excessive salivation and 
bronchial secretion are stated by Galippe ( Etude toxicol. sur la Cuivre , 
Paris, 1875) to be characteristic. Death may occur in a few hours, 
preceded by convulsions, paralysis, delirium, anaesthesia, and other 
symptoms of great nervous disturbance, seemingly as the result of a 
direct action of the poison upon the nervous system. Sometimes a 
tendency to syncope is very marked. The urine is usually lessened or 
suppressed. Black urine, due to the presence of haemoglobin without 
unaltered blood-corpuscles, has been noted; in this case, after death all 
the tissues were found stained with altered blood, and evidently de¬ 
struction of the blood was an important factor in the fatal result (W. Y. 
Med. Record , xxi. 567); fatty degeneration of the liver was also found. 
If the patient survives for twenty-four hours, jaundice nearly always 
shows itself. After this, profound depression with nervous symptoms 
may develop and end in death; but not rarely a favorable issue results, 
in which case the symptoms of gastro-intestinal inflammation with fever 
develop themselves. In the experiments of Ellenberger and V. Hof- 
meister upon animals, hasmaturia and fatty degeneration of the liver 
were prominent phenomena {Arch. Wissen. Prakt. Thierheilk., x. 228). 
The copper is said to be eliminated more freely with the salivary and 
intestinal secretions than with the urine (Galippe, loc. cit., p. 41). 

As the action of the sulphate of copper is exceedingly rapid, any 
antidote to be of avail must be given at once and act quickly. Milk 
and eggs are almost always at hand, and are the most efficient antidotes. 
No time should be lost in attempting to separate the yelk from the 
white of the egg, but the egg should be broken into a bowl as quickly 
as possible, a little water added, and the whole stirred up and exhibited. 
The dose should be repeated several times, especially when there is 
vomiting. Soap or a fixed alkali may be given. The yellow prussiate 
of potash , when pure, is harmless, and precipitates instantly an in¬ 
soluble compound of copper from solutions of its salt. When it is to 
be had in time, it may therefore be used as an antidote to the sul¬ 
phate. The treatment of copper-poisoning after the administration of 
the antidote consists in meeting the indications as they arise; opium 
should be used freely. When death occurs, the results of gastro-intes¬ 
tinal inflammation are usually found; sometimes the intestine has 
a decided bluish tint, and occasionally submucous ecchymoses occur. 
In exceptional cases, it is said, there are no evidences of inflammation 
in the alimentary canal.* Fatty degeneration of the liver has been 
noted (W. Y. Medical Record , xxi. 567). 


* For a fatal case of repeated poisoning by copper, with much information of value to 
chemical experts, see La France Mid., September, 1874, abstracted in Half-Yearly Compen¬ 
dium, Jan. 1875. Bournevette and Yvon (Revue Scientijique, p. 859, 1874) found two hun- 




ASTRINGENTS. 


463 


If chronic copper-poisoning ever exist among workers in the metal, 
it must be very rarely. The chief symptoms are asserted to be “a 
coppery taste in the mouth, giddiness, pain in the bowels, vomiting, 
occasional diarrhoea, and wasting of the body.” Dr. Clapton {Med. 
Times and Gaz ., June, 1868) has pointed out, as characteristic, a green 
line upon the gums; this was also observed by Professor Taylor, but its 
constancy is not assured. Thus, a green line was found on the teeth 
of all but two or three of a number of workers in the metal examined 
by a committee of the London Clinical Society ( Transactions , 1870, p. 
13), but there was no line on the gums of any of them. Although 
Dr. Faulk ( Deutsche Klinik , ix. 376) asserts that the habitual use of 
acetate of copper produces progressive paralysis with failure of respi¬ 
ration and death, it seems to me clearly established that small quan¬ 
tities of the metal can be taken into the system without injury. Both 
Galippe and Drs. Burcy and Ducom have found the metal almost with¬ 
out influence upon dogs (. Archives de Physiol. Norm, et Pathol ., 1877, 
iv. 183). Galippe ( Comptes-Rendus , lxxxiv. 718) fed himself for one 
month on food containing a large amount of copper without causing 
any symptoms of intoxication. Further, copper is habitually used 
upon the continent of Europe, especially in France and Belgium, in 
the preparation of vegetables,—French peas, beans, etc., owing their 
attractive color to their treatment with copper, which can be chemically 
recognized in them. The possibility of injury resulting from the use 
of such food has been repeatedly investigated by French and Belgian 
commissions, and the general verdict has been that no harm is pro¬ 
duced. The fact that twenty millions of cans of these food-articles 
are consumed every year, and that after thirty-six years’ continuance 
of the custom it has not been established that any harm is done, is 
sufficient in itself to prove that the vegetables are not poisonous. For 
an elaborate recent discussion upon the subject, consult Bull, de VAcad. 
Roy. de Med. de Beige , vols. xix. and xx., 1885 and 1886. 

Cupri Acetas, U.S.— Acetate of copper is in deep-green, prismatic 
crystals, yielding a bright-green powder; while the impure subacetate, 
or verdigris , occurs in masses of a pale-green color, which are often 
composed of minute silky crystals. Both acetates closely resemble the 
sulphate in physiological, therapeutical, and toxicological properties, 
but are less active. 

ARGENTUM—SILVER. 

ARGENTI NITRAS—NITRATE OP SILVER. U.S. 

This is officinally prepared by heating together silver, nitric acid, 
and a small quantity of water. It is a heavy anhydrous salt, crystal- 


dred and ninety-five milligrammes of metallic copper in the liver of a woman who had taken 
the ammoniacal sulphate three months previously. Minute quantities of copper exist in the 
normal human body ( Bull. Therap., xciii. 88). 



464 


GENERAL REMEDIES. 


lizing in translucent, shining, rhombic plates, and having a styptic, 
exceedingly metallic, corrosive taste. It is soluble in its own weight of 
cold water. Hydrochloric acid or a soluble chloride throws down from 
its solution a white curdy precipitate wholly soluble in ammonia. For 
external use the crystals are melted and run into moulds, where they 
harden into round, grayish, brittle sticks, about the size of a goose-quill, 
and having a radiated crystalline fracture. These constitute the officinal 
Argenti nitras fusus. As only the pure salt will make well-formed 
crystals, the impure products are always manufactured into the prep¬ 
arations just named, which should therefore not be employed internally. 
When nitrate of silver, either in substance or in solution, is exposed 
to the conjoint influence of light and of even a minute portion of 
organic matter, it turns black, and is converted into an insoluble sub¬ 
stance, which has been believed to be metallic silver, but is more prob¬ 
ably an oxide. For this reason the white stains which it first makes 
when applied to living tissues soon blacken. 

Physiological Action. —Nitrate of silver coagulates albumen, and, 
when applied in its pure state to living tissues, acts as a caustic, coating 
them over with a white almost membranous film. The caustic action 
is, however, not a deep one, because penetration of the salt into the 
tissues is soon prevented by the thick and tough skin or stratum which 
is formed. When applied in a dilute solution it acts as an astringent, 
constringing the vessels and overcoming relaxation. Its local action, 
however, is not simply that of an astringent, but is certainly peculiar 
and apparently alterative to nutrition. 

When taken internally in sufficient dose, this salt, by virtue of its 
corrosive action, is a poison, producing gastro-enteritis ; but it also acts 
directly upon the nervous system. Orfila and other of the earlier 
observers experimented upon it by injecting it directly into the veins 
of animals. When exhibited in this way, it must, by coagulating the 
albumen of the blood, produce thrombi, to which the subsequent symp¬ 
toms are in greater or less measure to be ascribed. This method of 
experimentation can therefore throw but little light upon the action 
of nitrate of silver when taken into the stomach. 

It is evident that in the stomach the nitrate of silver cannot loner 

O 

maintain its integrity. Dr. Bogolowsky has found ( Virchow’s Archiv, 
xlvi. 413) that when the nitrate is added to a peptone it is readily 
dissolved, and that the solution formed does not coagulate albumen.* 
That in this or in some other analogous form silver is absorbed is 
proved by its having been found in various internal organs and by the 
discoloration which follows its protracted use. When it is exhibited 
for a long continuous period, the skin often acquires a peculiar bluish 
slate color, which may become very dark, and in decided cases the con- 


* For recent studies of this character, see Isidore Neumann ( loc. cit.), also A. von Frag- 
stein (Berlin Klin. Wochen., 1877, 294). 



ASTRINGENTS. 


465 


junctiva and even the mucous membrane of the mouth are involved. 
The silver is found in all the tissues of the skin below the rete Mal- 
pighii* (Frommann, Virchow's Archiv, xvii. 135; Riemer, Archiv d. 
Heilkunde , xvi. 296, xvii. 330; Neumann, Medizin. Jahrbucher, 1877, 
369). Professor E. Harnack asserts ( Arzneimittellehre , 1883, 410) that in 
all recorded cases of argyria at least thirty grammes of the salt have 
been taken. The staining of the skin is always preceded by a dark 
discoloration of the mucous membrane of the mouth and gums. Both 
Heller and Orfila failed to detect silver in the urine of animals taking 
it; but probably it is eliminated, though slowly and in very small quan¬ 
tities, by the kidneys. 

By an elaborate series of experiments, M. Chas. Rouget ( Archives de 
Physiologic , July, 1873, p. 356) has shown that upon all animals from a 
crab to a dog the soluble salts of silver act as a poison, causing in mam¬ 
mals vomiting and purging, and in them and the lower animals violent 
disturbance of the motor functions,* as shown by paralysis and con¬ 
vulsions, and of the respiration, ending finally in death by asphyxia. 
This is in accord with the observations of other investigators. MM. 
Rabuteau and Mourier have found that the almost instantaneous death 
which Charcot and Ball first noted as following the injection of a large 
dose of the nitrate of silver into the veins is due to a direct paralyzing 
influence of the drug upon the muscle of the heart. M. Rouget has 
never seen this form of death follow the hypodermic or internal ad¬ 
ministration of the poison, the heart always continuing to beat for a 
greater or less length of time after the cessation of respiration, and 
also retaining its irritability. 

As already stated, both convulsions and paralysis are present in 
acute argyria , or silver-poisoning. The convulsions are severe, gener¬ 
ally tetanic, and according to Rouget are plainly reflex. A peculiarity 
noted by Rouget is the persistence of the convulsions after the complete 
abolition of voluntary' movements. M. Curci affirms that they are due 
to excitation of the motor tract of the cord, and that this is preceded 
by a similar influence upon the sensory tracts ( London Med. Record , 
1877, p. 72). 

The death is due, in argyria, to cessation of the respiration; Rouget 
(loc. cit., p. 351) even states that he has witnessed the suspension of the 
latter function in the frog while the activity of the reflex movements 
was much beyond normal. In the dog and in the full-grown cat this 
asphyxia is accompanied by an outpouring of mucus in the lungs, pul- 


* In an elaborate study of the organs of a case of argyria, Riemer found the silver in 
the glomerules of the kidney, the intima of the aorta, the choroid plexus, and the mesenteric 
glands. He believes that it is never deposited inside the cells, but in the cellular tissue, and 
that the silver preparation is reduced in the intestines, and the fine particles of the silver 
carried in the blood and lymph. 0. Loew (PjlUger’s Archiv, xxxiv. 603) asserts, however, 
that the silver is deposited inside of the renal endothelium cells, and, as he has found that 
protoplasm has reducing powers, believes that the silver is reduced in the cells from a solution. 

30 



466 


GENERAL REMEDIES. 


monary congestion and oedema being found on post-mortem examination. 
Two theories have been propounded as to the cause of the asphyxia: 
one, that it is simply due to the choking up of the lungs by the conges¬ 
tion and the excessive secretion whose origin is an altered state of the 
blood; a second, that both the asphyxia and the lesions in the lungs 
have their origin in a direct action of the poison upon the nerve-centres. 

The first view has been especially supported by Krahmer and by 
Rabuteau and Mourier. Unfortunately, I have not seen the original 
papers of these physicians; but, according to Eouget, the basis of 
argument of Krahmer is simply the ecchymoses which he found in 
horses dead of the poison, while that of Rabuteau and Mourier is the 
fluidity of the blood after death, and the existence in it of granules 
which, on account of their solubility in ammonia, were believed to be 
the chloride of silver. The French observers were, however, almost 
certainly mistaken in their belief that these granules were chloride of 
silver, since ammonia dissolves hasmatin as freely as it does the chloride. 

In 1864 Charcot and Ball (Gazette Med ., 1864) made a series of ex¬ 
periments in which a silver salt that did not coagulate albumen was 
injected directly into the blood. They noted not only the respiratory 
embarrassment, but also that the hinder extremities were suddenly 
paralyzed, and concluded that both the asphyxia and the lung-trouble 
were due to an affection of the central nervous system. In 1869 Dr. 
Bogolowsky, of Moscow, studied (Virchow's Archiv , 1869, Bd. xlvi.) 
the action of a peptone of the nitrate when used hypodermically. He 
found, on examination of the blood of a poisoned animal, that the 
spectrum analysis ( loc. cit., p. 415) betrayed nothing abnormal; that 
the red corpuscles appeared paler and their outline more delicate than 
normal; that the white corpuscles were natural. On the other hand, 
Rouget (loc. cit ., p. 361) examined microscopically the blood of animals 
poisoned with the nitrate of silver, and found it perfectly normal. The 
only conclusion to be drawn from all this seems to me to be that at 
present there is no proof whatever that the symptoms of acute argyria 
are due to alterations in the blood. That the embarrassment of respi¬ 
ration is not due to local lesions in the lungs is abundantly shown by 
the experiments of Rouget, who found that while in all animals these 
respiratory symptoms are very prominent, in only a few species are 
decided pulmonic lesions found after death. From all these facts I 
think it highly probable, if not altogether certain, that the theory 
propounded by MM. Charcot and Ball is correct. That the motor dis- 
tui-bance is centric, not peripheral, in its origin, is shown by the fact 
noted by Rouget (loc. cit., p. 354), that the muscles and nerves preserve 
their excitability after the arrest of the respiration. 

The various facts which have been thus far brought forward in 
regard to the physiological action of silver, although interesting to the 
toxicologist, have very little reference to its therapeutic use, since it is 
never employed to produce an acute constitutional influence. 


ASTRINGENTS. 


467 


The action of the drug when exhibited continuously for a length of 
time in large doses has been investigated by Dr. Bogolowsky upon dogs 
and rabbits. lie found that it produced loss of appetite, wasting, slight 
lowering of bodily temperature, diarrhoea, diminution of the quantity of 
urine passed, with increase of its specific gravity and often with the pres¬ 
ence of albumen, and transitory paralysis. How far some of these symp¬ 
toms were due to the direct constitutional action of the poison, and how 
far to derangement of the digestion dependent upon its local influence, 
is perhaps an open question. The local action was avoided, howevei’, as 
much as possible, by the use of an albuminate or of the double phos¬ 
phate of silver and sodium, which does not coagulate albumen. Com¬ 
parative examinations of the blood showed that the luemoglobin was 
diminished by more than one-third. The blood was also rendered very 
aplastic, as was betrayed by the constant tendency to the formation of 
ecchymoses. As some one has suggested that the silver in these cases 
replaces the iron of the blood-corpuscles, Dr. Bogolowsky made a chem¬ 
ical examination of the latter, but failed to find any traces of silver in 
them,—no doubt because it was not there. The solid tissues were found, 
after death from chronic argyria, to be in an advanced stage of degen¬ 
eration, which especially affected epithelial structures. The first change 
was swelling and opacity of the cells, with obscuration of the nucleus. 
After this came fatty degeneration, fatty globules in the cell, destruc¬ 
tion of nucleus, and finally of the cell itself. The liver and kidneys were 
profoundly influenced, as was also the muscular structure, especially of 
the heart. These results obtained by Bogolowsky have been in the main 
corroborated by A. V. Bozsahegzi (Arch. Exper. Path. Pharm., ix. 295). 

The summary which has been here offered comprises all our knowl¬ 
edge of the physiological action of the preparations of silver. Unfor¬ 
tunately, it does not throw much light upon their therapeutic use. The 
results of the chronic poisoning are so closely analogous to those pro¬ 
duced under similar circumstances by antimony, arsenic, and probably 
other metallic poisons as to indicate that silver given internally acts 
upon the nutrition of the body,—in other words, that it is an alterative. 

Therapeutics. —By far the most frequent employment of nitrate of 
silver in therapeutics is for its local action, either upon the surface of 
the body or upon those mucous membranes that can be reached directly 
by the drug. 

As a simple caustic , the salt may be used whenever only a superficial 
action is required: for reasons already given (page 464), it is useless 
whenever it is necessary to produce a deep eschar. As a caustic and an 
alterative , it is applied in solid form to many ulcerated surfaces , for the 
purpose of destroying superficial diseased tissue and of substituting, 
when the eschar separates, a healthy for an unhealthy action. As an 
antiphlogistic , nitrate of silver acts not only as an astringent, but also 
in some way not clearly understood. In the various inflammations of 
the mucous membranes, such as conjunctivitis , faucitis, laryngitis , ureth- 


468 


GENERAL REMEDIES. 


ritis, etc., it is used very frequently, not only in the stage of relaxa¬ 
tion, but also in the beginning of the attack. In conjunctivitis , the solu¬ 
tion employed should not, under ordinary circumstances, be stronger 
than one or two grains to the ounce; and it should not be used at all 
if any corneal ulceration exists, since a deposit of silver is liable to 
occur and to produce opacity. In faucitis, the strength of the solution 
may vary from thirty to sixty grains to the fluidounce. Even a satu¬ 
rated solution can scarcely be looked upon as caustic to the more robust 
mucous membranes. In ordinary cases of sore throat , the application 
once a day or every alternate day is generally sufficient. It is best 
made by means of a good-sized camel’s-hair brush, each part of the 
inflamed surface being distinctly touched, and not the whole simply 
daubed or slopped over by means of a very large brush or a sponge 
probang, as is often done. In severe cases it may be necessary to use 
the solution twice a day. Dr. Carl Seiler states that while solutions of 
nitrate of silver of less than sixty grains to the ounce cause pain when 
applied to the throat, solutions of one hundred and twenty to two 
hundred and fifty grains act as local anaesthetics, relieving soreness, and 
usually arresting acute inflammations at once, if applied in the first 
twenty-four hours, before inflammatory exudation has occurred ( Journ. 
Amer. Med. Assoc., i. 266). In laryngitis , the solution may contain from 
ten to twenty grains to the ounce, and should be applied with a brush 
by the aid of the laryngoscopic mirror. An attack of urethritis may 
sometimes be aborted in its forming stage by the injection of a strong 
solution (grs. xii to fgi) of the salt; but the practice is of doubtful 
expediency, since when it fails it greatly aggravates the trouble. In 
the advanced stages of gonorrhoea , weak injections (grs. i or ii to fgi) are 
often very serviceable. 

Many years ago (1828) Mr. John Higginbottom originated the 
practice of treating erysipelas by the nitrate of silver, and his plan has 
received a great deal of commendation from authorities, but oertainly 
has not been generally adopted by the profession. One or two cases 
of bad results, from ulceration of the skin apparently due to the local 
application, have deterred me from giving the method a fair trial, and 
I do not feel able to offer any opinion upon the practice. Mr. Higgin- 
bottom has more recently ( Tract ., 1869, ii. 34) reaffirmed the value of the 
treatment, stating that its want of general adoption is due to its being 
so often imperfectly carried out, and gives the following directions: 

“The affected part should be well washed with soap and water, then 
with water alone to remove every particle of soap, then to be wiped 
dry with a soft towel. The concentrated solution of four scruples of 
the nitrate of silver to four drachms of distilled water is then to be 
applied two or three times on the inflamed surface, and beyond it on 
the healthy skin to the extent of two or three inches. The solution 
may be applied with a small piece of clean linen attached to the end 
of a short stick, the linen to be renewed at every subsequent applica- 


ASTRINGENTS. 


469 


tion. As the solution of the nitrate of silver is colorless, it is necessary 
to pass a little linen, just moistened, over every part where it has been 
used, in order to be equally diffused, so that no part may be left un¬ 
touched. In about twelve hours it will be seen whether the solution 
has been well applied. If any inflamed part be unaffected, the solution 
must be immediately reapplied. Sometimes, even after the most decided 
application of the nitrate of silver, the inflammation may spread; but 
it is then generally much less severe, and is eventually checked by 
repeated applications. It is desirable to visit the patient every twelve 
hours until the inflammation is subdued.” 

In superficial inflammations other than erysipelatous I have frequently 
used nitrate of silver in this way, often with great advantage. Freely 
applied to the skin of the whole finger, it will sometimes even abort a 
commencing felon, or, applied to the scrotum, an epididymitis. 

Internally, nitrate of silver is exceedingly useful in stomachic and 
to a less extent in enteric diseases, exerting no doubt a purely local 
influence. In that form of dyspepsia characterized by the vomiting of 
large quantities of yeasty fluid, it has yielded in my hands better re¬ 
sults than any other remedy; and the same may be said of chronic gas¬ 
tritis and of gastric ulcer. The rules of administration are identical in 
these three diseases. In the first place, regulation of the diet is impera¬ 
tive : if the case be a bad one, all eating of meals should be suspended, 
and the patient receive every two or three hours a cup of sweet milk, 
with sound toasted bread broken up and thoroughly softened in it. 
Nitrate of silver should be administered in pill form, one-quarter to 
one-half grain three or four times a day, taken when the stomach is 
empty. In very serious cases, when all food is rejected by the stomach, 
it is sometimes advisable to allow absolute rest for two or three days to 
that viscus, the patient being fed by the rectum, and only a little water 
and pills of silver with opium being taken by the mouth. Under these 
circumstances, the return to the usual method of taking food must be 
very gradual, at first only a tablespoonful each of milk and of lime-water 
being administered every hour. In chronic enteritis or colitis , nitrate of 
silver is sometimes of service, especially if there be ulceration. 

For its constitutional effects nitrate of silver is used solely in diseases 
of the nervous system. It was formerly given in epilepsy; but it has 
passed out of use. There is one serious objection to the employment 
of the salt,—namely, the discoloration of the skin which sometimes 
follows its continuous use. Again, it is not understood in what class 
of cases the drug is of especial value, and there is no means of judging 
as to its applicability to any individual case. When other means have 
failed, however, the nitrate of silver may be tried in epilepsy, the 
patient or his friends being informed that although with proper pre¬ 
cautions the chances of discoloration are very few, yet it may occur. 

In chronic inflammations of the spinal cord, whether affecting chiefly 
the posterior columns and constituting locomotor ataxia. , or the anterior 


470 


GENERAL REMEDIES. 


and giving rise to paraplegia, the nitrate of silver is one of the few 
remedies that are ever of any service: although it most frequently 
fails, yet it occasionally does good, and in some cases has apparently 
even permanently arrested the disease. 

Toxicology. —The symptoms produced by the ingestion of large 
doses of nitrate of silver are partly gastro-intestinal and partly cerebro¬ 
spinal. In some instances the one series of phenomena predominate ; in 
others, those of the other class. In a case at the Hopital St.-Louis in 
1839 ( Beck's Medical Jurisprudence , i. 675, Phila., 1863) the symptoms 
were insensibility, violent convulsions, and dilated pupils, with, on a 
partial return to consciousness, intense gastric pain; complete restora¬ 
tion of consciousness did not occur until eleven hours after admission, 
and the coma returned at intervals during several days. 

Vertigo, coma, convulsions, great muscular weakness, paralysis, with 
intense disturbance of respiration, are in these cases the manifestations 
of disturbed innervation; whilst the abdominal symptoms are those of 
gastro-enteritis. The diagnosis can generally be made by the discolora¬ 
tions of the lips and skin,—at first white, afterwards black,—and by 
the blackish or brownish vo mi t; when the customary antidote has been 
given, both vomit and stools are generally white and curdy. At post¬ 
mortem the stomach and bowels are found corroded, often ecchymosed 
and with patches of a white or grayish color. Poisoning by nitrate of 
silver is not common, and I know of but three fatal cases,—one in 1837 
(Taylor, Medical Jurisprudence , 2d ed., vol. i. p. 319), one in 1861, a 
woman killed by fifty grains in solution in divided doses, and one in 
1871, a child destroyed by a piece of the solid stick three-quarters of 
an inch long, in spite of the use of the antidote (Scattergood, Brit. 
Med. Journ., May, 1871). 

The treatment consists in the administration at once of large 
amounts of common salt ,—the chemical antidote,—the constant use of 
large draughts of milk, and the meeting of symptoms as they arise. 

The fatal dose of silver varies very much, according, no doubt, to 
the presence of substances capable of decomposing it in the stomach. 
Thirty grains have killed; and recovery has taken place after the in¬ 
gestion of an ounce (case, Husemann, Toxicologie, Berlin, 1862, p. 868). 

Chronic argyria, or discoloration of the skin by silver, is usually 
unaccompanied by disturbances of health, although in severe cases 
the discoloration affects not only the skin, lips, gums, and sclerotic, but 
even the internal organs, such as the liver, spleen, and kidneys. It is 
therefore not due, as has been thought, to the chloride of silver, since 
the latter becomes dark only under the influence of the light, but to a 
deposition of silver itself or of its oxide.* Dr. S. Krysinski ( Bond. Med. 
Bee., August 16, 1886) found the granules in almost every tissue of the 

* According to Rdzsahegzi, Hermann has seen one ease in which preceding the deposition 
of the silver there were malaise, emaciation, failure of memory, singing in the ears, deafness, 
and spasms of the ocular muscles. 



ASTRINGENTS. 


471 


body, and states that they are an organic compound of silver, the 
exact nature of which has not yet been determined. The minute 
quantity of the metal present is shown by the analysis of Versmanns 
( Virchow's Archiv, xvii., 1859), who in 14.1 grammes of dried liver found 
only 0.0068 gramme of metallic silver (0.047 per cent.), and in 8.6 
grammes of dried kidney 0.053 gramme (0.061 per cent.). Greater or 
less success has been claimed for various treatments in argyria, but 
in general they are equally futile. Rogers states that blistering will 
lighten the color very much, and Eichmann asserts (Husemann, Toxi¬ 
cologies 871) that he has cured two cases by the use of potash baths 
and of soap baths, each four times a week. The older authorities 
commend the use of iodide of potassium internally. Dr. L. P. Yandell 
has reported ( American Practitioner , June, 1872) two cases in which 
large doses of the iodide were given for many months for syphilis, and 
the mercurial vapor-baths used at the same time for the same purpose, 
with the result of a complete cure of the argyria. The fading was 
gradual. 

Administration.— The nitrate of silver should always be given in 
pill, and, when it is desired to obtain its constitutional influence, after 
meals, during the process of digestion; but when its local action on the 
alimentary canal is required, it should be administered one or two hours 
before meals; and if the bowels are to be reached, the pill should have 
been made some time and be heavily coated, so as to be dissolved as 
slowly as possible. When it is given in epilepsy or other chronic dis¬ 
ease, its administration should be suspended for one week at the end 
of every third week, and its employment should not extend over a 
longer time than three months without a protracted intermission. 

Argenti nitras dilutus, U.S., is a grayish, solid substance, often in 
crayons, composed of equal parts of the nitrates of silver and potassium. 
It may be used as a very mild caustic. 

The oxide of silver (Argenti Oxidum, U.S.) is an olive-brown powder, 
very slightly soluble in water, which the United States Pharmacopoeia 
directs shall be prepared by precipitating the nitrate of silver with 
solution of potassa. It has been introduced into medicine as a substi¬ 
tute for the nitrate, with the idea that it would accomplish in diseases 
of the nervous system all that that drug is capable of, and at the same 
time not discolor the skin. With our present knowledge of the method 
of absorption of the nitrate, this seems highly improbable, and it is 
contradicted by experience. (Case, Phila. Med. Times, vi. 204.) Oxide 
of silver is not caustic when locally applied, but probably exerts some 
astringent action, and it has been commended in pyrosis. In nervous 
affections it is probably of equal value with the nitrate. The dose is a 
grain, in pill, three or four times a day. 

The cyanide of silver (Argenti Cyanidum, U.S.) is used solely for 
the preparation of hydrocyanic acid. The iodide (Argenti Iodidum, 
U.S.) has been used as an alterative, but is of very doubtful value. 


FAMILY IL—TONICS. 


MINERAL TONICS. 

FERRUM—IRON. 

Since iron constitutes a necessary integrant portion of the red blood- 
corpuscles, it is a food rather than a medicine. A very large propor¬ 
tion of the various articles of ordinary diet contain a trace of it; and 
as, according to Quevenne, it is very rarely to be found in normal urine, 
it must accumulate in the system. When, however, the supply, from 
any cause, is insufficient, or the power of digesting and assimilating it 
is impaired, or an abnormal excretion of it occurs, or by direct discharge 
it is drawn off from the blood, as in hemorrhage, a less than normal 
amount of it exists in the body. When this is the case, the condition 
ordinarily known as anaemia existing, the circulating fluid contains 
comparatively few red disks. It is this state which constitutes the 
great indication for iron. Under its use, if the cause of the anaemia be 
prevented from operating continuously, the color returns to the cheeks, 
because there is an absolute increase of the haemato-globulin in the 
blood. Thus, Professor Simon (Animal Chemistry , London, 1845, Syd. 
Soc. ed.) reports a case of chlorosis in which, under the steady use of 
iron for sixty-four days, the globulin increased from 30.86 parts to 90.80 
parts per thousand, and the haemoglobin from 1.431 parts to 4.598 parts 
per thousand; and Cutler and Bradford (Amer. Journ. Med. Sci., 1878, 
p. 78) have obtained confirmatory results with Malassez’s tubes. This 
increase is certainly due in part simply to the supply of the peculiar 
food of the red corpuscles; but it seems probable that the iron acts not 
merely as a food, but also as a veritable stimulant to the organs which 
produce these bodies. Since, however, we have no definite knowledge 
as to the early history of the red disks, it is evident that any theory as 
to the method in which iron increases their number must be a mere 
conjectui'e. It has been generally believed that iron, given to the 
healthy subject, would induce a condition of excess of the red blood- 
corpuscles. Recent exact investigations, while somewhat in discord, 
offer evidence calculated to unsettle our belief. The experiments of 
Nasse ( Lond. Med. Record , 1877, p. 498) upon dogs are in favor of the 
older view, while those of E. C. Cutler and E. II. Bradford are in oppo- 
472 



TONICS. 


473 


sition to it.* The first observer, giving iron with fat, noted not only an 
increase of bodily weight, but also that the specific gravity of the blood 
rose from 1052 to 1060.8, and the amount of the metal in the blood 
from 0.477 to 0.755 per thousand parts, both the result of increase in 
the corpuscular element. Cutler and Bradford experimented upon man, 
using the tubes of M. Malassez, the result being slight diminution of 
the red blood-disks. As, however, the experiments were only two in 
number, and the subjects not under complete control as to conditions 
of life, their observations can hardly be considered conclusive. 

It appears to be a well-established fact that one of the functions of 
the red blood-corpuscles is to convert oxygen into ozone, which is the 
efficient form of the element in the system (see paper by A. Sasse, 
Vierteljahresschrift fur Prakt. Heilkunde, 1866, Band ii.). The oxide 
of iron outside of the body certainly possesses an ozonizing power 
similar to that of the red disk. Thus, a spot of iron mould, i.e., irou 
oxide, on linen will in time destroy the fabric. The reason of this is 
the corroding action of the ozone which is slowly generated by the 
oxide of iron. From a similar cause a fleck of rust on a bright surface 
of steel will steadily enlarge and deepen. It would seem a priori proba¬ 
ble that in the blood iron acts as it does out of the body. If this be 
so, by increasing oxidation an increase of the iron in the blood should 
cause elevation of temperature and increased elimination of urea. The 
studies of W. Pokrowsky ( Virchow's Archiv, Bd. xxii.) have shown that, 
in cases of antemia, after the exhibition of iron the temperature does 
rise, even when in the beginning it was not below normal, and that 
simultaneously there is an increase in the daily elimination of urea; 
and the experiments of Botkin, as quoted by Sasse (I have not seen the 
original), establish the same fact in regard to healthy men. The in¬ 
creased oxidation cannot be due simply to an increase in the number of 
the red corpuscles, for while the latter accrues slowly, Pokrowsky found 
that the temperature sometimes rose within five hours after the exhibi¬ 
tion of the first dose. It would seem, therefore, that iron acts directly 
on the blood as an ozonizing agent. 

Iron in very minute quantity (Quevenne, Archives de Physiol ., de 
Therap. et d'Hygiene, Oct. 1854, p. 93) is at times present in normal 
urine, and the exhibition of it as a medicine increases the percentage. 
According to the researches of Quevenne (p. 95), the elimination of 
the ordinary medicinal salts of iron is always very slight; but the ex¬ 
periments of Becquerel (Simon’s Chemistry , vol. ii. p. 264) are not in 
accord with this. The amount of iron in the urine was found by him 


* Drs. V. H. Meyers and F. Williams {Arch. f. Exper. Path. u. Pharrn., xiii. 76) have 
studied the effects of enormous doses of the tartrate of iron and sodium upon the lower ani¬ 
mals. Both frogs and mammals are killed by it,—the symptoms in warm-blooded animals 
being vomiting, purging, great fall of the blood-pressure, muscular weakness, and finally coma 
and death. The experiments show that the heart is not much affected, but the vaso-motor 
system and the spinal motor centres are paralyzed. 



474 


GENERAL REMEDIES. 


to vary, in those taking ferruginous preparations, very greatly and 
unaccountably from day to day, but the elimination commenced as 
soon as the administration. Dr. Zaleski (. Arch.f. Exper. Path. u. Pharm., 
xxiii.) believes that bis researches have shown that iron is especially 
eliminated by the liver. According to Quevenne, the haloid salts escape 
in the urine much more freely than do the other preparations. 

Almost all the preparations of iron are more or less astringent, 
and when in the blood very probably exert a direct influence upon the 
tissues, contracting them not merely by increasing their tone, but also 
by acting on their vital contractility. 

The preparations of iron may be divided into those which are soluble 
and those which are insoluble in water. At first sight it would appear 
that the former class of preparations would be those most readily ab¬ 
sorbed. The experiments of Quevenne ( loc. cit .) have, however, de¬ 
monstrated that these soluble preparations are largely precipitated by 
the gastric juice even when it is strongly acid. This precipitate is 
probably an albuminate, mixed, when the gastric juice is alkaline, 
with the oxide of the metal. It has been further demonstrated by 
Quevenne that these precipitates do not yield so large a percentage of 
material to the acid gastric juice as do some of the insoluble salts. 
According to Mialhe (Ghimie appliquee, Paris, 1856), after the entrance 
of an iron salt into the blood its power of acting as a ferruginous 
tonic depends upon its capability of being decomposed by the alkalies 
of the blood in such a way as to give origin to albuminates. From 
these considerations it would appear that the question of solubility in 
water is of very little importance in the choice of a chalybeate. Que¬ 
venne has demonstrated that the reduced iron yields the largest per¬ 
centage, and, as it is nearly free from astringency, it is probably the 
best chalybeate. If a soluble preparation be desired, the amnionic or 
potassic tartrates are very unirritating. If Mitscherlich be correct in 
his deductions, the protosalts are more readily absorbed than the sesqui- 
salts, and consequently should be preferred as a general rule.* 

There are some persons in whom iron produces headache : this can 
only sometimes be obviated by the use of laxatives. The observations 
of M. Petit, Dr. H. A. Bubnow, etc. ( Zeitschr. f. Physiolog. Chern ., vii.), 
that the iron preparations in large doses inhibit the digestive processes, 
throw some light ujion these cases. 

When iron is exhibited in the usual doses, only a small propor¬ 
tion is absorbed, the remainder escaping with the faeces, to which it 
imparts a black color. This black color is due to a conversion of the 
iron into tannates and sulphurets,—the tannic acid of the first com¬ 
pound being derived from the food, the sulphur of the second from 
the intestinal gases. 


* I have left this as in earlier editions: the subject of the absorption of iron urgently 
needs re-investigation. See also Berlin. Klin. Wochenschr., 1877, p. 420. 



TONICS. 


475 


Therapeutics. —The chief indication for the use of iron is the ex¬ 
istence of anaemia; the contra-indication, a state of plethora : on these 
points sufficient has already been said, and the peculiar actions of cer¬ 
tain salts will be considered under their respective preparations. The 
preparations of iron which are recognized by the U.S. Pharmacopoeia 
are unnecessarily numerous. 

Ferrum Reductum—Reduced Iron. U.S.—This preparation is also 
known by the names of Ferri Pulvis, Iron by Hydrogen , and Quevenne's 
Iron , and is as a chalybeate the best of all the various medicinal forms 
of iron. It is made from the subcai’bonate (sesquioxide) by exposing 
it at a white heat to the action of hydrogen, which takes away the 
oxygen and leaves the pure metallic iron. It occurs as a light, iron- 
gray, tasteless powder, which should be completely dissolved by dilute 
sulphuric acid without yielding the odor of sulphuretted hydrogen, and 
when touched with a lighted taper should ignite and burn to the brown 
oxide of iron. If it be black, or if it fail to answer the tests given 
above, it is impure; and indeed, as offered in the shops, not rarely it 
is entirely spurious. Of all the efficient preparations of iron it is the 
freest from astringency. The dose is from two to five grains, taken 
in pill form after meals. As it is entirely tasteless, it is frequently 
given to children in chocolate-drops or lozenges, which are taken as 
confectionery. 

Ferri Oxidum Hydratum—Hydrated Oxide of Iron. U.S. — The 
Hydrated Sesquioxide of Iron, made by precipitating the tersulphate 
with ammonia, is a reddish-brown powder, which is used solely as an 
antidote to arsenic. For this purpose it should be freshly prepared, 
and should be so moist as to constitute a magma. Its virtues are de¬ 
teriorated by age, even when it is kept under water, and are entirely 
destroyed by drying. If the solution of the tersulphate of iron be not 
at hand in an emergency, the perchloride will yield just as useful a 
product, and carbonate of sodium may be substituted, if circumstances 
necessitate it, for the ammonia. The precipitate falls at once, and 
may be washed by putting it in a piece of muslin, squeezing out the 
original fluid, and then pouring on some fresh water. As the sesqui¬ 
oxide of iron is perfectly innocuous, it should be very freely admin¬ 
istered when used as an antidote, especially since it acts only when in 
excess. A teaspoonful to a tablespoonful of it should be stirred up in 
water and taken at once, the dose being repeated several times if neces¬ 
sary. The Ferri Oxidum Hydratum cum Magnesia , U.S., differs from 
the hydrated oxide in containing magnesia, which is substituted in 
excess for the ammonia as a precipitant. As magnesia is not at all 
irritant, and is itself antidotal to arsenic, this new preparation offers de¬ 
cided advantages over the older antidote. It should be given promptly 
and freely. 


476 


GENERAL REMEDIES. 


Ferri Carbonas Saccharatus. U.S.— Saccharated Carbonate of 
Iron. —This greenish-gray powder is made by precipitating a syrupy 
solution of the sulphate of iron by bicarbonate of sodium. Throughout 
the subsequent washings, and during drying, sugar is kept constantly 
present in large amount, so as to prevent the absorption of oxygen, 
and the consequent conversion of the protocarbonate into the sesqui- 
oxide. This is a very good chalybeate, nearly free from astringency, 
and may be given in doses of from three to five grains, in pill form. 
Pilules Ferri Composites, U.S., contain the protocarbonate of iron and 
myrrh. They are sometimes used in anaemia with amenorrhoea; one 
to three pills three times a day. The Mistura Ferri Composita, U.S., is 
a liquid preparation containing substantially the same ingredients as 
the compound pills. Dose, one to two tablespoonfuls. 

Ferri Sulphas—Sulphate of Iron. U.S. (FeO,SO s -j-7HO— 
FeS0 4 -f-7H 2 0). The pure protosulphate of iron is made by dissolving 
iron in dilute sulphuric acid. It occurs in transparent efflorescent 
rhombic prisms of a pale bluish-green color and a metallic styptic taste. 
The sulphate of iron is a very decided astringent, and in a concentrated 
form and sufficient amount acts as an irritant poison, producing vomit- 
ing, purging, and gastro-intestinal inflammation.* Externally its solu¬ 
tion (five to twenty-five grains to the fluidounce) is used as an astringent 
lotion. It has been especially recommended in this form (§i to Oj) in 
erysipelas. As a simple chalybeate the sulphate of iron should never 
be used. In chronic diarrhoea it is sometimes employed as a tonic astrin¬ 
gent. Dose, five grains; in the form of the dried sulphate ( Ferri Sul¬ 
phas Fxsiccatus, U.S.), three grains. Ferri Sulphas Prcecipitatus, U.S., 
is simply a pure ferrous sulphate obtained by precipitation, and may be 
used instead of the older preparation. 

Liquor Ferri Subsulphatis—Monsel’s Solution. U.S.—The solu¬ 
tion of the subsulphate [of the sesquioxide] of iron (often incorrectly 
called solution of the persulphate of iron) is a most powerful astringent 
and styptic, and is used solely as such. It is but slightly irritant, and 
is the best of all the astringents for stanching hemorrhage when it 
can be applied directly to the part, as in external wounds, or in hesma- 
temesis. In hemorrhage from the stomach, ten drops of it may be 
given in a tablespoonful of water, the dose being repeated as necessary. 
Applied by means of the atomizer, it is often very efficient in hcemop- 
tysis. In such a case the fluid to be atomized should have the strength 
of from five to twenty drops to the ounce. The inhalation should last 
from five to fifteen minutes, and be repeated at intervals of an hour 
or longer. It is very essential that the liquid should be finely pulver- 

* In a case reported in the N. Y. Med. Journ., xxxviii. 401, the early symptoms, as 
stated by the patient, were chiefly nervous: little confidence can, however, be reposed in the 
patient’s report of symptoms or of the amount ingested. 



TONICS. 


477 


ized. In diphtheria , Monsel’s solution is very valuable applied freely, 
of full strength or diluted pro re nata , to the throat every three to 
twelve hours. In overdose, Monsel’s solution is an irritant poison: the 
antidote is soap or an alkaline carbonate. 

The Solution of the Tersulphate (Liquor Ferri Tersulphatis, U.S.), 
owing to its irritant action, is used only to make the sesquioxide prep¬ 
arations. 

Tinctura Ferri Chloridi—Tincture of Chloride of Iron, U.S., con¬ 
tains the sesquichloride of iron, hydrochloric acid, and alcohol, and, from 
the reactions of the last two ingredients, hydrochloric ether. It is pre¬ 
pared by adding alcohol to the officinal Liquor Ferri Chloridi , and is a red¬ 
dish-yellow, astringent, irritating, somewhat corrosive liquid. It is an 
excellent chalybeate, possessed of peculiar properties, probably in some 
measure due to the ether which it contains. It is a diuretic, increasing 
often very decidedly the daily urinary secretion. It appears also to 
exert an astringent influence upon the urino-genital mucous membrane, 
and is frequently employed with tincture of cantharides in gleet. In 
chronic Bright's disease it is often of very great service as a chalybeate 
diuretic. In erysipelas it is constantly employed with remarkable re¬ 
sults, controlling the disease in a manner not yet understood. Analogy 
has suggested its employment in other adynamic affections, such as 
diphtheria and pyaemia , but its value in these diseases is much more 
doubtful. Locally it is used as an astringent in sore throat; for this 
purpose its strength should be reduced at least one-half. As it is very 
destructive to the teeth, care ought to be exercised in its use about the 
mouth, and also in its administration. The dose is from fifteen to 
thirty drops, given as a chalybeate three times a day; in erysipelas, 
every two or three hours. The orange-yellow crystalline deliquescent 
Sesquichloride of Iron (Ferri Chloridum) (Fe 2 Cl 3 —Fe 2 Cl 6 ) is officinal, 
but is very rarely used. 

Syrupus Ferri Iodidi. U.S. — The Syrup of Iodide of Iron contains 
7.33 per cent, of the dry protiodide of iron in the fluidrachm, and is 
made by agitating iron, iodine, and water together, and adding hot syrup. 
It is a transparent, greenish liquid, of a sweet, ferruginous taste. It 
deposits no sediment on keeping, and should not affect the color of 
starch. If it strikes a blue color with the latter substance, it contains 
free iodine. The syrup of iodide of iron is a favorite remedy in those 
cases of anaemia in which there is a distinct scrofulous taint. It is 
believed to possess the peculiar alterative powers of iodine, conjoined 
with the tonic properties of iron. It is much used in scrofulosis oc¬ 
curring in anaemic children; but it certainly possesses no advantages 
over a ferruginous tonic and iodine when given separately but simul¬ 
taneously. Indeed, it seems to me uncertain whether its use is as effec¬ 
tive as the separate administration of iodine and iron. The dose of it 


478 


GENERAL REMEDIES. 


for a child two years old is five to ten drops; for an adult, thirty to 
forty minims. As it affects the teeth very seriously, it should always 
be freely diluted when taken, and the mouth should be well washed 
after its administration. 

Ferri Iodidum Saccharatum. U.S. — Saccharated Iodide of Iron is 
a yellowish-white or grayish powder which represents the chemical and 
medical properties of the corresponding syrup, being prepared by a 
parallel process. It may be substituted for the syrup in doses of from 
two to five grains given in pill form. 

Dialyzed Iron. — Ferrum Dialysatum .—This is a clear, neutral, nearly 
tasteless, dark-red liquid, prepared by dialyzing a solution of the chlo¬ 
ride of iron. Its exact chemical composition is uncertain. It contains 
a minute proportion of chloride, and it is possible that the iron exists 
as a basic oxychloride. It bears dilution with pure water, but is at 
once precipitated by alkalies, almost all soluble salts, and many organic 
substances. As the iron oxide in this condition is unable to pass through 
animal membranes, it has been asserted that it cannot be absorbed. 
Clinical experience shows, however, that it is absorbed, and a priori it 
seems certain that the dialyzed iron must undergo change the moment 
it enters the stomach. In what form absorption takes place we do not 
know. Its tastelessness, harmlessness to the teeth, and comparative 
freedom from astringency have rendered it a favorite chalybeate, not¬ 
withstanding its feebleness. The assertion frequently made that it never 
constipates is an error. It should never be used in combination. The 
dose is twenty to forty drops. Dialyzed iron is antidotal to arsenic. 
It is harmless, and in cases of poisoning a tablespoonful should be ad¬ 
ministered at once, and repeated pro re nata (see Fhila. Med. Times , 
vol. viii. pp. 104, 151, 335). 

There are four officinal Citrates of Iron , all soluble in water.* Two of 
these (Ferri Citras and Ferri et Ammonii Citras) occur in garnety- 
red scales, and are simply mild chalybeates. Dose, five grains. The 
Citrate of Iron and Quinine (Ferri et Quinine Citras) is in transparent 
scales, varying from reddish brown to yellowish brown in color, with a 
tint of green. The Citrate of Iron and Strychnine (Ferri et Strychnine 
Citras) contains one per cent, of strychnine. 

There are two officinal Tartrates of Iron (Ferri et Ammonii Tartras 
and Ferri et Potassii Tartras), both occurring in garnety scales, and 
both soluble in water. Dose, five grains. The Lactate of Iron (Ferri 


* Dr. Glaevecke (Arch. f. Exper. Path. u. Pharm., xvii. 466) has experimented upon 
rabbits by the hypodermic injection of citrate of iron. He finds that the iron appears in the 
urine in half an hour, that the maximum proportion is reached in two to four hours, and that 
after twenty-five hours elimination ceases. In man he states that these injections are well 
borne, and tbe therapeutic effects satisfactory. The dose of the citrate used for an adult was 
about 1.5 grains. 



TONICS. 


479 


Lactas, U.S.) occurs in greenish-white crystalline crusts or grains, sol¬ 
uble in forty-eight parts of water. It is a good chalybeate. Dose, five 
grains. There are two officinal Phosphates of Iron , which may be used 
in five-grain doses. Ferri Phosphas is a bright slate-colored insolu¬ 
ble powder. Ferri Pyrophosphas is an excellent preparation, occur¬ 
ring in apple-green scales, somewhat soluble in water, and nearly free 
from astringency and ferruginous taste. Ammonio-ferric Alum (Ferri et 
Ammonii Sulphas, U.S.) occurs in octahedral crystals of a pale violet 
color. It is freely soluble in water, is very astringent, and is used only 
in atonic leucorrhoea, in which affection marked benefit is often gained 
by the exhibition of it in five-grain doses three times a day. Bro¬ 
mide of Iron (not officinal) has recently been highly recommended by 
Dr. Da Costa in chorea and incontinence of urine in children ( Medical 
and Surgical Reporter , 1874). He gives, to a child, five grains, dissolved 
in syrup, and rapidly increases the dose to twenty grains. In a few 
trials I have found it useless in chorea. 

Manganese. —The Black Oxide of Manganese (Mangani Oxidum 
Higrum, U.S.), and the Sulphate (^angani Sulphas, U.S.), have been 
supposed by some to possess therapeutic properties similar to those of 
iron. The metal manganesium certainly exists in the blood, but its 
salts have failed to gain the confidence of the profession, although 
highly recommended by Harmon, of Belgium, and by Petrequin (A r ou- 
velles Recherches du Manganese , 2d ed., Paris, 1852, also Bull. Therap., 
March, 1852) as an adjuvant to the chalybeates. In Dr. Garrod’s ex¬ 
periments upon amemia ( Med. Times and Gaz., 1863) the preparations 
of manganese failed to be of service. C. C. Gmelin is said ( U.S. Dispen¬ 
satory') to have found the sulphate act as a powerful cholagogue on the 
lower animals; and Dr. Thomson states that it is a purgative to man 
in doses of one or two drachms. Dr. Leand affirms ( Glasgow Med. 
Journ ., Jan. 1865) that the oxide of manganese is therapeutically equiva¬ 
lent to the preparations of bismuth excepting in that it does not con¬ 
stipate, and that it may be used with advantage in gastralgia , pyrosis, 
and similar stomachic derangements. 

fr 

ACIDUM SULPHURICUM—SULPHURIC ACID. U.S. 

Oil of Vitriol (S0 3 ,H0—H 2 S0 4 ) is when pure a colorless, heavy 
liquid (sp. gr. 1.843). On exposure to the air it rapidly absorbs moist¬ 
ure and becomes less dense. When its specific gravity is 1.78, it de¬ 
posits crystals of the bihydrated acid at 28° F., and may burst the glass 
in which it is kept. Owing to its great affinity for water, it is used in 
chemistry as a desiccant. 

Physiological Action.— Concentrated sulphuric acid is powerfully 
corrosive of both animal and vegetable tissues, abstracting the elements 
of water and leaving the carbon untouched. It consequently blackens 


480 


GENERAL REMEDIES. 


organic matter at the same time that it destroys its texture.* When 
administered in therapeutic doses and absorbed into the blood, it is con¬ 
verted into sulphates, and as such, so far as is known, is eliminated. 

It escapes by the kidneys, as has been proved by Dr. H. Bence 
Jones (. Lectures on Pathol, and Therap., London, 1867) in regard to 
large therapeutic doses, and is attested by Maukopff as occurring after 
poisoning. As, however, the amount of elimination by the kidneys 
seems to be slight, it is very probable, as Dr. Headland ( Action of 
Medicines , London, 1852) conjectures, that it is excreted both by the 
lower bowel and by the skin. Locally applied, dilute sulphuric acid is 
an astringent, and clinical experience proves that it exerts a similar 
action when taken into the system. Under such circumstances its 
astringent influence is most marked upon the skin and intestine,—parts 
which are believed to excrete it: it is therefore possible that this action 
is in a measure local, and dependent upon the presence of the excreted 
acid.f 

Therapeutics. —Concentrated sulphuric acid is not rarely used as 
an escharotic, for which purpose it is mixed with finely-powdered 
charcoal so as to form a paste. Appropriately diluted, it has been used 
as a stimulant and astringent lotion in venereal and other indolent ulcers. 
Internally, sulphuric acid is very useful as an astringent in colliquative 
sweats ( night-sweats) and in profuse serous diarrhoeas. I have used it 
with great advantage in the sudden serous vomiting and purging of 
infants known as cholera infantum. 

It has been employed with advantage in cholera , and a remarkable 
series of observations by Dr. R. G. Curtin ( Phila. Med. Times , vol. iii. 
p. 649) at least furnish good reason for further testing its powers as 
a prophylactic against this disease. The facts recorded by Dr. Curtin 
are as follows. A very severe epidemic of the disease ceased in the 
Insane Department of the Philadelphia Almshouse within twelve hours 
after the lunatics were all put upon the free use of sulphuric acid 
lemonade; the only new case after this being in a man who refused to 
use the prophylactic. Two days after the use of the sulphuric acid 
was stopped, two new cases occurred, and the epidemic was again 
arrested by the use of the acid. In the surgical wards of the Hospital 
Department the acid was used from the beginning of the epidemic; 
and these wards, although in no way isolated, were the only parts of 
the institution unvisited by the disease. 

Sulphuric acid was formerly used in hemorrhages , but is now rarely 

* The observation of Ore ( Comptes-Rendus , 1875), that considerable quantities of dilute 
acids can be injected into the blood without causing coagulation or serious disturbance, has 
been confirmed by Dr. Paul Guttmann ( Virchow’8 Archiv, lxix. 534). The acid is probably at 
once neutralized by the alkali of the blood. 

t The action of large but not corrosive doses of mineral acids upon animals has been to 
some extent studied by Dr. F. Hofmeister (Prager Med. Wochenschr., 1879, iv. 75). Death, 
he believes, results from asphyxia, due to the acidification in the blood of the alkaline salts, 
which serve as vehicles in carrying the carbonic acid from the tissues. 



TOXICS. 


481 


employed. It is, I think, much less efficacious than some other reme¬ 
dies. In acute lead-poisoning the dilute acid is an efficient antidote, and 
it has been proposed by M. Gendrin (Dr. Bennett, Lancet , 1856) as a 
remedy in chronic lead-poisoning. As, however, he combined its internal 
exhibition with the daily use of warm sulphur-baths, it is doubtful how 
much of the successful result was due to its action. It is difficult to 
perceive how it can do good in these cases, and I do not think the 
clinical proof that it does so has as yet been brought forward. 

Toxicology.— When swallowed in concentrated form, sulphuric acid 
acts as a corrosive poison. Death from collapse has resulted in two 
hours and a half (case, Med. Times and Gaz., vol. i., 1863), but usually 
the course of sulphuric acid poisoning is much more protracted, the 
fatal result having been delayed in some cases for several months. The 
usual symptoms are pain in the mouth, throat, and epigastrium, violent 
vomiting, often of tarry matters, with symptoms of collapse, such as 
cold extremities, feeble pulse, suppressed voice, and clammy skin. The 
mind is generally clear to the last. Profuse, and sometimes bloody, 
salivation is commonly present. The parotids sometimes swell as early 
as the fourth day, and Maukopff ( Syd. Soc. Year-Book , 1863) has seen 
suppurative parotitis apparently induced by closure of the duct of 
Steno, retention of secretion, and consequent irritation of the gland. 
The later symptoms are those of ulceration of the oesophagus and 
stomach, and need not be dwelt upon here. The larynx is often pro¬ 
foundly affected. There is a very marked increase in the amount of 
sulphates in the urine, which may be albuminous and contain granular 
casts. Desquamative nephritis may be developed several days after the 
subsidence of the first symptoms. Thus, in one of the cases reported 
by Maukopff, urine which had ceased to be albuminous on the third day 
became so again on the twentieth, with a simultaneous development of 
casts containing blood-corpuscles; after death tubular nephritis was 
found. Another symptom noted by Maukopff was intercostal neuralgia. 

After death, greater or less destruction of the oesophagus and the 
stomach, or of the air-passages, is found. The black color of the slough 
is a diagnostic sign which an examination of the mouth will sometimes 
render available before death. 

The most important part of the treatment of sulphuric acid poison¬ 
ing consists in the immediate and free exhibition of the antidotes, which 
should be given in milk or in water. The best antidotes are chalk, mag¬ 
nesia, whitewash, and soap. Christison condemns the use of the alka¬ 
line carbonates, because they are themselves irritating. As, however, 
in these cases time is a matter of vital importance, if the alkaline car¬ 
bonates be the only antidotes at hand they should be used unhesitatingly. 

Administration. —Sulphuric acid should of course be given properly 
diluted, and with the requisite precautions to prevent its injuring the 
teeth. It is best administered in the form either of the dilute (.Acidum 
Sulphuricum Dilutum —1 to 9, U.S.; sp.gr. 1.082; dose, ten to thirty 

31 


482 


GENERAL REMEDIES. 


drops) or of the aromatic sulphuric acid (Acidum Sulphuricum Aromati- 
cum —1 to 5, U.S.). The last preparation contains alcohol and aro¬ 
matics. Its dose is from ten to twenty drops. 

ACIDUM HYDROCHLORICUM—HYDROCHLORIC ACID. 

U.S. 

Hjffirochloric acid is a colorless aqueous solution of hydrochloric 
acid gas, having the specific gravity of 1.160, and containing rather 
more than 33.9 per cent, of the gas. The hydrochloric or muriatic acid 
of commerce commonly has a yellowish tint, produced by sesquichloride 
of iron, or sometimes by organic matter. 

Physiological Action.— In its concentrated form hydrochloric acid 
is highly corrosive, but less so than either sulphuric or nitric acid. Its 
astringent properties are not all decided, if indeed it really possess 
any. As it probably is one of the natural acids of the stomach, it 
would seem as though it ought to be capable of aiding digestion. It 
also appears to have influence over the glandular system of the ali¬ 
mentary canal, increasing by its action their normal secretions. 

Therapeutics.— In stomachic dyspepsia , muriatic acid, with or with¬ 
out pepsin, is often useful by aiding in the digestion of the food. In 
other cases, where the dyspepsia is intestinal , with a tendency to diar¬ 
rhoea and loss of appetite, muriatic acid combined with strychnine and 
some aromatic, such as compound tincture of cardamom, is often very 
advantageous. In low fevers the use of mineral acids has been highly 
extolled by various authorities. 1 have seen a number of cases treated 
upon this so-called “ Swedish plan,” and have never been able to perceive 
that the acids do any real good. 

Locally , diluted muriatic acid has been recommended by Bretonneau 
in diphtheria. He employed a mixture of one part of the acid to two 
parts of honey; but bolder practitioners have used it of full strength, 
with, it is asserted, good effect. It should be applied by means of a 
little mop, scrupulous care being exercised to prqyent any of the acid 
from coming in contact with parts not protected by false membrane. 

Toxicology.— Hydrochloric acid, as a poison, is similar in its effects 
to, but less powerful than, sulphuric acid, recovery having occurred 
after the ingestion of an ounce of the officinal acid ( Boston Medical and 
Surgical Journal , vol. xv.). The treatment is similar to that of poison¬ 
ing from other mineral acids. 

Administration.— The acid is best given in the form of the officinal 
Acidum Hydrochloricum Lilutum (£iv to Oj ; sp. gr. 1.038). Dose, ten 
to thirty drops, properly diluted. 

ACIDUM NITRICUM—NITRIC ACID. U.S. 

A liquid of the specific gravity of 1.420, which as first made is color¬ 
less, but by exposure to the light acquires a yellow tint. It oxidizes 
all of the common metals except gold, and is exceedingly corrosive to 


TONICS. 


483 


living tissue, which it stains an indelible yellow. When diluted it 
converts most animal and vegetable substances into oxalic, malic, or 
carbonic acid. 

Physiological Action. —When applied to any portion of the living 
organism, nitric acid acts as a most powerful chemical caustic. When 
very greatly diluted, it is a simple local stimulant, with very slight 
astringent powers. Owing to its chemical activity, its vapor was at 
one time used as a disinfectant; but it has been superseded by other 
substances. Taken internally in small amount, it acts as a stimulant 
upon the glandular system of the alimentary canal, and in serous diar¬ 
rhoea appears to exert an astringent influence. It seems to me very 
probable that these effects are local rather than constitutional, due to 
a direct action of the acid upon the mucous membrane of the bowel. 
On entering the blood, nitric acid must be converted into a nitrate. 
In regard to its elimination we have but little definite information, 
but it probably escapes through the same channels as does sulphuric 
acid. 

Therapeutics. —Nitric acid is used quite frequently as an escharotic, 
especially in cases of chancres and venereal or other warts. In its em¬ 
ployment care should be taken to protect the sound tissue by oil, or, 
still better, by a layer of soap. It may be applied by means of a splinter 
of wood, or, if it is to be used more freely, by a little mop. When it has 
penetrated as deeply as is desirable, washing the part with warm soap¬ 
suds will prevent further action. Very much diluted (five to twenty 
drops to the ounce), it forms a good stimulant lotion for indolent ulcers. 
It should not be emploj^cd as a mouth-wash, on account of its destructive 
action on the teeth. Of course this does not apply to its use as a caustic 
in cancrum oris, in which, as in other forms of acute gangrene, such as 
phagedenic chancres and hospital gangrene, it is very efficient. In these 
cases it must be applied thoroughly. 

Internally, nitric acid has been used in low fevers, but with doubtful 
advantage. In dyspepsia, in chronic hepatic congestion, in the oxalic acid 
diathesis, in the dyscrasia of coyistitutional syphilis, nitric acid has been 
employed with advantage, but is much inferior to nitro-hydrochloric 
acid. 

In 1826 Dr. Hope claimed for Acidum Nitrosum a specific action in 
serous diarrhoea, including the sudden acute diarrhoeas of hot climates, 
and in the chronic dysenteries originating under similar circumstances. 
The formula he employed is as follows: R Acidi nitrosi, f 3i 5 Misturae 
camphorae, f^vih; Misce, et adde Tinct. opii, gtt. xl. S.—A fourth 
part to be taken every three or four hours. Under the name of Hope's 
Camphor Mixture a preparation similar to this has been much used, but 
has gradually lost the confidence of the profession, chiefly, I believe, 
because on theoretical grounds the original formula has been departed 
from. The Nitrous Acid of the shops ( Acidum Nitrosum, Edinburgh 
Pharmacopoeia) is an orange-red liquid, which may be looked upon as 


484 


GENERAL REMEDIES. 


a solution of nitric oxide in nitric acid. When it is diluted with water 
it is after a short time converted into simple nitric acid. For this reason 
it has been customary to substitute nitric acid for the Acidum Nitrosuin 
of Hope’s original formula. It should be noted, however, that the latter 
only provided sufficient of the remedy to last a few hours, and, as the 
reaction which has been spoken of requires some time for its perform¬ 
ance, I do not think that theory in truth warrants the change. Practi¬ 
cally I have failed absolutely with the new formula, when immediate 
relief was afterwards obtained by the use of the medicine prepared 
according to the old plan. Made in this way and used while fresh, 
Hope’s Camphor Mixture is a very efficient though disagreeable remedy 
in diarrhoeas connected with disordered secretion of the liver and other 
glands of the alimentary canal. 

Administration.— The dose of the strong acid is from five to twenty 
drops; of the diluted (Acidum Nitricum Dilutum —1 to 6, U.S.; sp. gr. 
1.068), from fifteen to sixty drops. 

Toxicology.— When taken in a concentrated form, nitric acid is a 
corrosive poison, exceeding even sulphuric acid in violence. The symp¬ 
toms so closely resemble those induced by the latter substance that it 
is unnecessary to detail them here, as is also true of the treatment. 
The distinguishing character is to be found in the color of the affected 
tissues, which in nitric acid poisoning are stained of a deep yellow. 

ACIDUM NITRO-HYDROCHLORICUM—NITRO-HYDROCHLO- 

RIC ACID. U.S. 

This preparation is made by mixing three parts of nitric with five 
parts of hydrochloric acid. If the acid is sufficiently strong, an orange- 
colored liquid is formed, with the evolution of intensely-irritating vapors. 
After standing for a length of time, the red color changes to a golden 
yellow. It is in this state that the United States Pharmacopoeia directs 
the acid to be used. By longer standing the golden yellow becomes 
lemon-ye llow, and the odor of chlorine is almost entirely lost. These 
changes are hastened by light, but will occur in the dark and in well- 
stoppered bottles. Although the golden-yellow acid is directed by the 
Pharmacopoeia, yet careful clinical studies have convinced me that the 
acid acts much more efficiently when freshly prepared and of a deep- 
red color. In some cases it has seemed to me useful only when in the 
latter form. The lemon-yellow acid is nearly valueless. 

Physiological Action.— Concentrated nitro-hydrochloric or nitro- 
muriatic acid is exceedingly corrosive. Our knowledge of its action in 
small doses is purely clinical, and will be spoken of under the head of 
Therapeutics. The chemistry of the acid is so complex and uncertain 
that no reasonable conjecture can be made as to the form in which it is 
absorbed or the method of its escape from the body. That it is absorbed 
in some form is proved by its occasionally producing salivation, even 
when applied to the skin by means of baths. 


TONICS. 


485 


Therapeutics.-*— The remedial value of nitro-hydrochloric acid de¬ 
pends chiefly upon the power which it possesses to a much greater 
degree than any other of the mineral acids of influencing the action of 
the liver and other glandular organs of the alimentary canal. Origi- 
nally proposed by Dr. Scott, of Bombay, in the chronic hepatitis of hot 
climates, it has been used with great success by Annesley, Martin, and 
other famous India surgeons. The remedy would seem not to be indi¬ 
cated in hepatitis with high fever and a tendency to rapid suppuration 
so much as in the slower form of the affection, which normally ends 
in chronic enlargement and induration of the viscus. In the habitual 
congestion of the liver occasionally seen in this climate I have used it 
with the most marked benefit. In the still milder affection known as 
“ biliousness ,” whose pathology is probably a torpid condition of the 
small glands of the alimentary mucous membrane as well as of the 
liver, nitro-muriatic acid has yielded in my hands most excellent results. 
That the remedy does act upon the liver is proved by the fact that in 
these cases it sometimes produces violent bilious diarrhoea. When 
jaundice depends upon obstruction or upon any of the severer organic 
diseases of the liver, the acid is of-little if any use; when, however, 
the jaundice depends upon torpor of the liver, or even when it is catar¬ 
rhal in origin, the remedy may be of great service. Even in the early 
stages of cirrhosis , while the liver is still enlarged, nitro-muriatic acid 
should be tried, as in some cases apparently of this character great 
benefit has been derived from its use. 

In those forms of chronic diarrhoea in which the disease is really an 
intestinal dyspepsia, nitro-hydrochloric acid may be of the utmost ser¬ 
vice, benefiting and even curing cases which have resisted other treat¬ 
ment. As the effect of the acid is not a sudden one, it is evident that 
it acts in these cases not as an astringent, but by restoring the normal 
digestive power. 

There is a morbid condition, probably dependent upon defective 
primary assimilation, in which the chief symptoms are general malaise, 
a feeling of weakness, a lack of elasticity, and a very great depression of 
spirits, in which crystals of oxalate of lime are generally to be found 
in the urine, and in which nitro-muriatic acid produces in a few days 
a surprising revolution. 

As a “ blood-purifier” the acid has been employed in constitutional 
syphilis , and in various ulcerative skin-affections. In these diseases it 
no doubt does good by improving digestion and increasing glandular 
action; but there is no reason to believe that it is a direct alterative. 

Administration.— For reasons which have already been given, when 
nitro-muriatic acid is administered internally it should be freshly pre¬ 
pared ; and, as the changes which have been spoken of take place more 
rapidly when the acid is mixed with water, the officinal dilute nitro- 
muriatic acid is an ineligible preparation. As light hastens its deterio¬ 
ration, the strong acid should always be kept in a dark bottle with a 


486 


GENERAL REMEDIES. 


glass stopper. Directly after mixing the acids the evolution of gas 
may be so great as to necessitate its being allowed to escape. After 
six or eight hours, however, the bottle should be closely stoppered. 
The dose of the strong acid is from five to eight drops, properly diluted, 
and taken through a tube after meals. 

In chronic hepatic diseases the external application of the acid seems 
to give even better results than its internal use. In India, according 
to Sir Puinald Martin, the bath is used as follows. Take Hydrochloric 
acid fgiii, Nitric acid fjii, Water fgv. Mix. Two gallons of water 
and six fluidounces of the above mixture suffice for a bath, which will 
keep fit for use during three days, provided half a fluidounce of acid 
and a pint of water are added morning and evening. The bath must 
of course be given in wooden or earthenware vessels, and if it becomes 
necessary to warm it only a portion should be heated, and the rest then 
added. In urgent cases the whole body may be immersed in the bath ; 
but generally a foot-bath is preferable, the inside of the thighs and 
arms and the hepatic region being at the same time sponged. The 
bath should be repeated twice daily, lasting each time for ten or fif¬ 
teen minutes. 

I have had no experience in this method of using nitro-muriatic 
acid, but have derived great benefit from the application of the acid 
over the hepatic region. My plan has been to wring out a large piece 
(eight by ten inches) of spongio-piline, or of canton flannel (several 
layers), in a lotion of a strength varying, according to the irritability 
of the patient’s skin, from one to three fluidrachms to the pint, and to 
apply this over the right hypoehondrium, covering it with a piece of 
oiled silk supported by a bandage. The application sometimes causes 
a prickling sensation, and after a time may produce a jjrofuse local 
sweating. The dressing may be left on from half an hour to an hour, 
and be repeated three or four times a day: some patients can wear it 
almost continuously. 

Toxicology. —When taken in poisonous doses, nitro-hydrochloric 
acid produces symptoms and results similar to those following the in¬ 
gestion of nitric acid. The color of the stain produced by it is yellow, 
and its antidotes are the same as those of other mineral acids. 

Lactic Acid (Acidum Lacticum, U.S.) appears to be the natural 
acid of the gastric juice, and may with propriety be used as an adju¬ 
vant to pepsin in doses of half a drachm three times a day. W. Preyer, 
conceiving that sleep is due to the presence in the blood of the results 
of tissue-change, among which is lactic acid, experimented with it and 
its soda salt, and announced that they acted as powerful soporifics 
upon both man and the lower animals {Gentralhl. f. Med. TFisseas., 1875, 
p. 578). According to his statements, with the sleep came deep, slow 
respiration, and lessening of reflex activity and of the bodily tempera¬ 
ture. Subsequent papers by Dr. E. Mendel ( Deutsch. Med. Wochenschr ., 


TONICS. 


487 


1876, No. 17), Dr. Erler (Centralbl. f. Med. Wissens ., 1876, p. 658), Dr. 
Fischer ( Lond. Med. Record , 1877, p. 193), Dr. Lothar ( Virchow's Archiv, 
lxvi. 120), and Dr. Senator ( Berlin . Klin. Wochenschr., 1877, p. 537), 
have shown that the hypnotic powers of lactic acid and its salts are 
very feeble and uncertain. The large doses used also are very prone 
to produce irritation of the alimentary canal, and Senator noticed the 
production of rheumatic pains. From three to nine drachms of the 
lactate of sodium may be given at a dose. 

PHOSPHORUS. (P.) U.S. 

Phosphorus is a translucent, when pure nearly colorless, but usually 
slightly yellowish, highly inflammable elementary body, which is taste¬ 
less, but possessed of a peculiar alliaceous odor. It is obtained from 
the phosphate of calcium of calcined bones, by taking away the lime 
with sulphuric acid and deoxidizing the residuum by heating with 
charcoal. It is insoluble in water, sparingly soluble in ether, absolute 
alcohol, and the oils, freely so in chloroform. It takes fire at 100° F., 
and melts at 108° F. In the shops it is in cylindrical sticks, covered 
with a whitish layer, and having when cut a waxy consistence and 
lustre. When properly treated, it is converted into several allotropic 
forms, the red phosphorus, black phosphorus, and the crystallized 
metallic phosphorus of Hittorf. The first of these is the most impor¬ 
tant ; it is brittle, does not take fire at ordinary temperatures, and is 
said not to be poisonous. 

Physiological Action. —The physiological action of phosphorus 
in therapeutic doses is probably entirely different from that which it 
exerts when in larger amounts. It is a constituent of most of the more 
important tissues, and is especially abundant in the nerve-centres. Like 
iron, cod-liver oil, etc., it appears to act when given in minute quantity 
as a stimulant to the nutrition of the tissues, into whose composition 
it enters. So far as the nervous system is concerned, this assertion 
rests chiefly upon clinical observation; but Dr. Wegner ( Virchow's 
Archiv , June 22, 1872) has experimentally demonstrated such an action 
upon the bony tissues. He found that when adult animals were fed 
upon minute doses of phosphorus the spongy tissue in the long and 
short bones was thickened, and the compact tissue was rendered more 
dense. After a time new tissue was deposited upon the inside of the 
shafts of the long bones, in some instances until the marrow-cavity was 
obliterated. The action upon the bones of growing animals was even 
more marked. 

Phosphorus was at one time believed to be a diffusible stimulant, 
and it possibly may exert such an influence. In the acute nervous 
exhaustion of typhoid pneumonia I have once or twice seen it appar¬ 
ently act favorably in this way. 

For reasons to be hereafter adduced, it is certain that in poisonous 
doses phosphorus acts as phosphorus, and when it is administered 


488 


GENERAL REMEDIES. 


therapeutically it certainly enters the blood in its elemental form, and, 
I believe, acts as such. Dr. Wegner advances the following reasons for 
believing that it does not act as phosphoric acid so far as the bony 
tissues are concerned. First, no similar action can be obtained from 
phosphoric acid unless from eight hundred to one thousand times the 
proportional dose be given. Second, the newly-formed tissue is at first 
gelatinous. Third, there is no excess of phosphates in the bone. 
Fourth, when the food is deprived of lime the same new tissue arises, 
but remains in a soft, gelatinous state. 

Therapeutics. —The chief use of phosphorus in medicine is as a 
nutrient tonic to the nervous system. In all cases of chronic nervous 
exhaustion , whether involving the cerebral or the spinal centres, it is of 
great value. I have seen marked benefit from its use when the symp¬ 
toms were not severe enough to indicate organic lesion; but the most 
remarkable results have been in the cases in which the structure of 
the centres was apparently deeply implicated. In threatening cerebral 
softening , in myelitic paraplegia from excessive venery, it is the only 
drug which appears really to affect the nerve-centres. 

Attention has recently been called by several writers to its virtues in 
neuralgia; and, as neuralgia is often simply an expression of exhausted 
nerve-power, the use of phosphorus is commended by reason as well 
as by experience. 

It is probable that it may be of value in some cases of impaired 
vitality, although the nervous system be not obviously implicated. Dr. 
II. Eames ( Dublin Journ. Med. Sci., Jan. 1872) states that he has ob¬ 
tained great benefit from its use in obstinate skin-affections, such as 
lupus, acne, and psoriasis. It has also been asserted to be useful in 
cataract.* 

On account of its marked influence on the development of bone, 
Dr. Wegner suggested its use in osteomalacia and in rickets, and Dr. 
Friese states ( Berlin. Klin. Woch., 1877, p. 437) that he has had brilliant 
success from its use in combination with iron in several cases in which 
ordinary treatment had failed. The recent elaborate article of M. Kas- 
sowitz (Zeitschrift f. Klin. Med., 1884, 115) confirms this specific action 
of phosphorus, and I think it should be persistently administered to 
all rachitic children. Professor Samuel E. Percy has used phosphorus 
successfully for repeated f uruncular eruptions ( Trans. Amer. Med. Assoc., 
1872, p. 659). 

Toxicology.— The ingestion of a fatal dose of phosphorus is not 
followed by any sensible effects for some time. After, however, from 
three to twelve hours a sense of weakness and of general wretchedness 
manifests itself, and in a large proportion of the cases (according to 
Lewin, eighty-eight per cent.) is accompanied, or soon followed, by 


* Dr. Tavignot, Revue de ThSrapeutique Medico-Chirurgicale, August and September, 
1871; Professor Gioppi, Giornale d’ O/talmologia, abstract in N. Y. Medical Record, 1872. 



TONICS. 


489 


vomiting. With the emesis there is nausea, and in most cases the 
patient soon complains of abdominal pain, the severity of which, how¬ 
ever, never equals that of corrosive poisoning. The matters vomited 
consist of food, mucus, and bile. During the first eight or ten hours 
they often smell strongly of phosphorus, and are luminous in the dark. 
The vomiting may persist during the whole attack, but generally ceases 
on the second or third day, to reappear with the subsequent jaundice, 
when coffee-colored vomit from exuded blood is ejected. The pain, 
which in most cases abates with the vomiting, often spreads from the 
epigastrium over the whole abdomen, and in rare instances is parox¬ 
ysmal. If it reappear in the latter stages, it is apt to affect especially 
the right hypochondrium, and is associated with decided tenderness in 
the region named and in the epigastrium. 

The tongue is whitish or abnormally red, sometimes furred. There 
is generally fever, loss of appetite, and thirst. Maukopff has noted a 
morning and evening temperature of from 37° C. to 39° C. and from 
37.4° C. to 39.8° C. respectively. During the latter part of the case 
there is very often a remarkable fall in the temperature, which is 
generally, but not always, a precursor of death. The lowest point I 
have seen noted was 31.2° C. (88.2° F.) some hours before death.* In 
some cases fever is altogether absent, or comes on just before death.f 

The stools are at times normal in character and frequency, but there 
is general diarrhoea or constipation, with flatulence. Late in the attack 
the passages are in most cases very light clay-colored, or even whitish, 
and exceptionally they are bloody. In some cases they are phospho¬ 
rescent. 

Jaundice comes on in from thirty-six hours (cases reported by Mau¬ 
kopff, Wien. Med. Wochenschr., 1863, and by Tiingel, Klin. Mittheilungen 
Abtheilung des Allgemein. Krankenh. in Hamburg , 1861) to five days 
(Lebert and "Wyss, Archives Generates , 6th series, xii., Sept. 1868) after 
the ingestion of the poison. In most cases it appears first in the con¬ 
junctiva, but sometimes the urine gives previous warning of its ap¬ 
proach. In some cases there is with it a decided and palpable increase 
in the size of the liver, which may pass, if the patient live long enough, 
into an equally apparent lessening of the bulk of the viscus. The 
severe nervous symptoms are rarely, if ever, developed until after the 
jaundice, although early in the attack there is not unfrequently anxiety, 
headache, giddiness, and dreamy unquiet sleep, or even sleeplessness. 
The more pronounced nervous symptoms consist of delirium, which 
may be wild and is very fi*equently erotic, with somnolence ending in 
coma and death, occasionally preceded by convulsions. According to 
Taylor, the latter are a certain sign of approaching dissolution. Very 
generally, partial spasms and fibrillar contractions of the voluntary 


* See case of Dr. Battmann, Archiv cler Heilkunde, 1871, p. 257. 
f See case of Concato, Sydenham Soc. Year-Book, 1869-70, p. 454. 



490 


GENERAL REMEDIES. 


muscles occur, although there is always, in not too rapid cases, pro¬ 
gressive paresis of the voluntary muscles. Death is usually put off 
beyond twenty-four hours, yet it has occurred in a child in four hours 
and in the adult in seven hours after the ingestion of the poison 
( Wien. Med. Wochenschr., May, 1884, 608). The patient may suddenly 
succumb to collapse and cardiac paralysis, but more commonly he dies 
comatose from a gradual failure of the respiration and circulation. 

If recovery occur, it is by a gradual amelioration of the symptoms, 
and the health of the patient is apt to be impaired for some time. Ap¬ 
parently desperate cases will sometimes convalesce unexpectedly; and 
Tiingel states that a favorable issue may take place even after violent 
delirium. 

The urine is almost always much affected by the poison. Yery com¬ 
monly it is scanty, is albuminous, and sometimes it contains sugar. 
As was first pointed out by Munk and Leyden ( Die acute Phosphorver- 
giftung, Berlin, 1865), after jaundice has set in, bile-acids, as well as 
biliary coloring-matter, are always to be found in the urine. Hot un- 
frequently a cloudy sediment consisting in part of epithelial cells, often 
tinged with bile, is deposited. Dr. Oswald Kohts ( Pfluger's Archiv, Bd. 
iii. p. 1) and other observers have found leuein and tyrosin in the urine 
of dogs poisoned with phosphorus, and undoubtedly these substances 
are sometimes to be met with in the human excretion. The albumi¬ 
nuria generally follows, but may precede, the icterus. A very remark¬ 
able and apparently constant constituent of the urine is the sarco-lactic 
acid. Fat has been found in the urine inside of renal epithelial cells, 
and also as free globules (Schutz, Prag. Med. Wochenschrift, 1882, vii. 
322). 

Phosphorus induces in animals symptoms parallel with those com¬ 
monly seen in man; although Kohts states that he ha^ seldom seen 
albuminuria in animals, even when the structure of the kidneys was 
profoundly altered. Orfila, Magendio, Munk, and Leyden found that 
the only effects following the injection of phosphuretted oil into the 
jugular vein of an animal were the exhalation of phosphoric acid 
and broncho-pulmonary inflammation: on examination (Munk and 
Leyden), oil, but no phosphorus, was found in the lungs. Ludimar 
Hermann and Alfred Brunner ( Deutsch. Arch.f. Klin. Med.., p. 198) have 
shown that in these experiments there was embolic arrest of the oil in 
the pulmonary capillaries, and consequent inflammation with subsequent 
oxidation of the phosphorus. When the phosphuretted oil is injected 
in the form of a fine emulsion, the characteristic symptoms and post¬ 
mortem appearances of phosphorus-poisoning result. 

In some instances phosphorus-poisoning presents symptoms quite 
different from the typical array. Death may take place in a few hours, 
and in such cases jaundice is not generally present (case, Lancet , 1879, 
ii. 311). Zeidler reports a death in forty-two hours, from suppression 
of urine, with collapse and erotic delirium. In a case of Bollinger’s 


TONICS. 


491 


(Deutsches Archiv f. Klin. Med., Bd. vi., 1870) the chief symptoms were 
vomiting,- pain and tenderness over the abdomen, great weakness of 
pulse, gradually-developed paralysis of the legs, and death, without 
jaundice, in four and a half days. The autopsy revealed hemorrhagic 
effusion between the membranes and the spinal cord, and also into the 
sheaths of the proximal portions of the spinal nerves. 

In women, fatal doses of phosphorus very commonly produce a 
bloody pseudo-menstrual discharge, and when pregnancy exists almost 
invariably induce abortion or miscarriage. M. Miura has found in the 
foetus of poisoned rabbits structural changes similar to those of the 
mother ( Virchow's Archiv , xcvi. 54). 

The older toxicologists spoke of an erosive gastritis as a common 
result of phosphorus-poisoning, but it is now well established that such 
affection is very rarely induced by the drug.* As was first pointed out 
by Virchow ( Virchow's Archiv, Bd. xxxi., 1864), there is universally a 
gastro-adenitis, which causes the gastric mucous membrane to be thick¬ 
ened, opaque, whitish, grayish, or yellowish-white. Under the micro¬ 
scope the epithelial cells appear swollen and filled with granules and 
oil-globules, and in very advanced degeneration the cells completely 
break down. This gastro-adenitis is not due to a local action of the 
phosphorus, because it occurs when the poison is introduced through 
other channels than the mouth. The duodenum and intestines suffer 
similar changes. The liver is generally very much enlarged, friable, 
and light-colored; sometimes it is mottled, and sometimes portions of 
it are deeply stained with bile.f The cells are gorged with fat-glob¬ 
ules, J and in some cases there are small-celled interstitial thickenings 
due to hyperplasia of the trabecular tissue. The gall-bladder may be 
full or empty. In protracted cases the liver undergoes atrophy, with 
destruction of its secreting cells. The kidneys, especially in their 
cortical portion, suffer a degeneration similar to that of the liver, the 
epithelium becoming enlarged, granular, fatty, and finally undergoing 


* It would appear probable that if it occurred at all it would be in rapidly-fatal cases; 
yet Tiingel did not find it in a patient dead in nine hours of phosphorus-poisoning ( Vir¬ 
chow’s Archiv, Bd. xxx., 1864). 

f According to researches made by Dr. Emile Rousseau in the Pathological Laboratory 
of the University of Pennsylvania, the first anatomical changes in the liver occur in the centre 
of the lobules around the hepatic vein. 

{ A. Lebedeff {Arch. f. Physiol., xxxi. 11, 1883) believes that the fat in the liver is not 
produced by degeneration of the hepatic tissue, but has simply been transported there from 
the subdermal regions. He bases this opinion upon his own observations,—first, that the 
phosphorus fat has the same chemical constitution as has the subdermal fat ; second, in a dog 
which had been fed with linseed oil and then poisoned with phosphorus, the liver was loaded 
with linseed oil. This evidence is of very little value, because on the one hand the linseed 
oil probably accumulated in the dog’s liver before the poisoning and simply remained over, 
and on the other hand there is no proof that fat produced by degenerative changes necessarily 
differs in composition from other fat. The fact that the liver and other organs are destroyed 
in phosphorus-poisoning may be considered proof that the fat is formed out of the affected 
tissue. 



492 


GENERAL REMEDIES. 


destruction. The voluntary and cardiac muscles, the spleen, the lungs, 
and probably all the tissues, partake of the universal fatty degenera¬ 
tion* which AVesmer has shown to involve even the minute arterioles. 

O 

The blood is often profoundly affected, becoming very dark, losing 
its power of coagulation, and apparently suffering also in its corpus¬ 
cular elements; for ecchymoses are almost universal, and haematin 
crystals are occasionally found in the viscera. In the case of Concato 
( loc. cit.) the white corpuscles were observed during life to be increased 
in number, and the red to be diminished in size and altered in form. 
The ecchymoses occur in all parts of the body, but are apt to be es¬ 
pecially pronounced in the mediastinum and the serous membranes. 
Schiff has found that in dogs, after death from phosphorus, the blood 
does not pass into the veins, but remains in the arteries (Archiv f. Exper. 
Path. u. Therap., Bd. ii. p. 347). 

Dr. Mayer states that when very large doses of poison have been 
taken, the blood and even the urine (?) may be phosphorescent ( Can- 
staffs Jahresbericht , 1862, Bd. v. p. 123). 

The elimination of bile-acids in the urine shows that the jaundice 
of phosphorus is caused not by an arrest of secretion, but by an oc¬ 
clusion of the biliary passages and consequent resorption of the bile. 
Dr. O. Ivohts (loc. cit.) has apparently demonstrated that the occlusion 
is most frequently due to the duodenitis involving the common duct, 
so as to obliterate its lumen by the swelling of the mucous membrane. 
In some cases, however, it is probable, as believed by "Wyes, Alter, and 
Ebstein, that a catarrhal inflammation of the minute gall-ducts is the 
cause of the jaundice, and also that the result is in part effected through 
pressure upon those ducts by the swelling of the glandular and tra¬ 
becular tissue.f It is proper to state that Demarbaix and Willmart 
(Presse Med., xxi., 1869, and Schmidt's Jahrb., Bd. cxliv. p* 152) insist 
that the icterus is not really heptogenous, but haunic in origin, chiefly 
because they have found hamiatoidin in the urine. This fact, however, 
proves only that the blood is altered by the poison: it does not disprove 
the liver-origin of the jaundice. 

Acute phosphorus-poisoning so closely resembles yellow atrophy 
of the liver that their clinical distinction is sometimes difficult, nay, 
impossible. Distinct phosphorescence in the breath, vomit, or stools 
would, of course, be direct evidence of poisoning. This phosphores¬ 
cence, however, very often cannot be detected: according to Vetter 

* The scope of the present work does not allow of a full discussion of the pathology of 
phosphorus-poisoning. The reader is referred to the following papers: Etudes cliniques et 
expirimentales sur VEmpoisonnement aigu par le Pliosphore, par Professor II. Lcbert et Dr. 
0. Wyss ( Archives Gin., Sept. 1868); Zur pathologischcn Anatomie der acuten Leberatrophie 
und der Phosphorvergi/tung, von Dr. Otto Bollinger (Deutsches Archiv f. Klin. Med., Bd. v., 
1869); and Ueber Icterus bei Phosphorvergi/tung, von Dr. 0. Kolits ([bid.). 

f For an elaborate discussion of the cause of jaundice, see Kohts’s paper, Deutsches 
Archiv f. Klin. Med., Bd. v. p. 168; consult also that of Dr. Bollinger, Centralbl. fur die 
Med. Wise., 1869, and Deutsches Archiv f. Klin. Med., Bd. v., 1869. 



TONICS. 


493 


( Virchow's Archiv, Bd. liii. p. 186), it can be rendered more evident in 
the vomit, stools, etc., by acidifying with sulphuric acid and warming 
in a shallow dish. When death ensues during the first week of phos¬ 
phorus-poisoning, the enlarged liver affords a distinctive proof of poi¬ 
soning ; but when the case is more protracted, the atrophied liver of 
phosphorus cannot be distinguished from that of the natural disease. 
The symptoms during life rarely, if ever, afford sufficient ground for a 
positive diagnosis. The lull in the symptoms after the first onset of 
the disease happens more generally in phosphorus-poisoning than in 
yellow atrophy. Yet the clinical differences between various cases of 
either affection are greater than those which have been relied upon as 
separating the two affections. Kohler has asserted that oxymandelic 
acid in atrophy of the liver replaces the sarco-lactic acid of phosphorus¬ 
poisoning, and stress has been laid upon the asserted facts that in the 
natural disease leucin and tyrosin are present in abundance in the urine, 
while in the poisoning they are absent. In yellow atrophy, however, 
tyrosin is not unfrequently absent from the urine, and leucin present in 
very small amount, while both principles may be present in phosphorus¬ 
poisoning.* In regard to the acids in the urine, very careful chemical 
analysis would in any case be necessary to determine their presence, 
and sufficient evidence is certainly not yet forthcoming to show that 
either of them is really characteristic. Chemical examination is there¬ 
fore absolutely necessary in all medico-legal cases. (For discussions of 
the diagnosis between yellow atrophy and phosphorus-poisoning, see 
Kohler, Syd. Soc. Year-Book , 1870, p. 455; Schultzen and Ries, Annalen des 
Berlin. Krankenhauses, Bd. xv., 1869; and especially Dr. I. Ossikovsky, 
Wien. Medizin. Presse, xiii., 1872, abstracted in Schmidt’s Jahrb., Bd. 
cliv. p. 15. For cases in which the question was legally raised, investi¬ 
gated, and discussed, see Schmidt's Jahrb., Bd. cxli. p. 167 ; Syd. Soc. Year- 
Book, 1832, p. 430; Annales d'Hygiene, Jan. 1869.) According to M. 
Poulet ( Gaz. Med. de Paris, Aug. 1872), phosphorus is eliminated as 
hypophosphoric acid, and the poisoning can be recognized by heating 
the urine with nitric acid to calcination. If hypophosphoric acid bo 
present, as dryness is reached the mixture suddenly bursts into a flame 
like a packet of matches. 

It has of late years been demonstrated that phosphorus passes into 
the blood as phosphorus, and not in the form of phosphoric acid or 
other compound. In poisoning-cases in men the breath is said some¬ 
times to be distinctly phosphorescent; and in animals Bamberger has 
found phosphorus in the blood, and Husemann and Marme in the liver, 
two or three hours after its ingestion; W. Dybkowsky (Hoppe-Seyler's 
Med.-chem. Untersuch., Heft i. p. 54) has detected it in the blood and 
liver ten hours after its ingestion; and other observers have demon- 

* Cases ( Wiener Med. Presse, 1872; Schmidt’s Jahrb., Bd. clxix. p. 127, Bd. cxcv. p. 123;. 
Professor Ossikovsky believes that the principles appear habitually about the sixth day of the 
poisoning, when the liver is still enlarged. 



494 


GENERAL REMEDIES. 


strated its presence in almost all of the tissues. It seems probable 
that to some extent it finds entrance into the circulation by being dis¬ 
solved in the various fatty matters contained in the alimentary canal. 
At the temperature of the body, however, it yields abundant vapors, 
and Bamberger has demonstrated that these readily and rapidly pass 
through animal membranes. He has found that defibrinated blood, 
when separated from the fumes of phosphorus only by an animal mem¬ 
brane, rapidly becomes saturated with the poison. Dybkowsky ( loc. 
cit.) has confirmed this, and it cannot be doubted that in a similar 
manner living blood absorbs the poison from the alimentary canal. 

W. Dybkowsky ( Hoppe-Seyler's Med.-chem. Untersuchungen , Heft i.) 
renders probable the theory of Schuchardt ( Henle und Pfeufer's Archiv , 
N. F., Bd. viii.) that the phosphorus to some extent in the alimentary 
canal, but much more largely in the veins, is converted into phosphu- 
retted hydrogen, and that some of this compound and some of the 
phosphorus itself is oxidized in the venous blood, so that phosphoric 
acid, besides phosphorus and phosphuretted hydrogen, is emptied into 
the arterial blood; further, that the last two compounds are oxidized 
at the expense of the arterial blood and the tissues it feeds, and that 
the poisoning is due to this deprivation of oxygen. For the details of 
the experiments upon which these conclusions rest I must refer the 
reader to the original memoir.* 

The indications for treatment in phosphorus-poisoning are very evi¬ 
dent. It is plain that no medication can influence the terrible organic 
lesions induced, and that the primary object must be to prevent the 
absorption of the poison. Emetics and purgatives are, therefore, of 
prime importance. The necessity of the persistent use of evacuants is 
shown by the finding of phosphorus by Dr. Starck in the stools three 
and a half days, and in the vomit two days, after the ingestion of the 
fatal dose ( Deutsches Archiv f. Klin. Med., xxxw. 482). As phosphorus 
is soluble in oils, no fatty matters should be allowed either in the food 
or in the medicines. As an emetic, sulphate of copper should always be 
chosen. 

The minute particles of phosphorus adhere so closely to the ali¬ 
mentary canal that they cannot be dislodged by mechanical means, and 
an antidote is urgently demanded. For the purpose of oxidizing the 
poison, Duflos suggested magnesia usta and liquor chlorini, and Scherer 
the chloride of lime; but in practice these substances have been found 
of no value, on account of the slowness of their action. 

The oil of turpentine, originally proposed by Andant ( Journal de 
Medecine de Bruxelles, 1868-69) as an antidote to phosphorus,f has been 


* M. LecorchS (Archives de Physiologie normale et patliologique, tome i., 1868, tome ii. 
1869) believes that phosphorus acts in the blood as phosphoric acid, but does not establish his 
opinion. For a discussion of this, see Dybkowsky’s paper. 

t For cases, see Gazette Hebdomadaire, 1874; Schmidt’s Jahrbiicher, Bd. clxix. p. 126; 
Med. Times and Gaz., 1876, ii. 461. 



TONICS. 


495 


largely used by experimenters, with apparently contradictory results, 
which, as is now known, were due to the employment of different 
varieties of the oil. There are in European commerce three varieties 
of turpentine,—the rectified, the German, and the French. Jonas 
(.Liebig und Wohler's Annalen der Chemie , Bd. xxxiv.) found that while 
the pure oil has no effect upon phosphorus, the acid French oil forms 
with it a crystalline, spermaceti-like mass. This is soluble in ether, 
alcohol, and alkaline solutions, and has received the name of turpen¬ 
tine-phosphoric acid. It is said to be eliminated by the kidneys un¬ 
changed, and to exert no deleterious influence. The elaborate experi¬ 
ments of Vetter on dogs and rabbits gave results in accord with these 
facts, for he found the rectified and German oils to be of no value in 
phosphorus-poisoning, while the crude acid French oil was distinctly 
antidotal. Koehler, however, asserts that when the German oil has not 
been rectified for some time, it acts upon phosphorus. He believes that 
the oil acts partly by oxidizing the poison and partly by converting it 
into the harmless turpentine-phosphorous acid. One part of the oil 
must be given for 0.01 part of the phosphorus. ( Detroit Review , 1873; 
from Med.-chirurg . Rundschau , Jurre, 1873. Case of recovery, Guy's 
Hospital Reports , xxvi. 13.) Ordinary American oil of turpentine and 
Canada balsam are of no value in phosphorus-poisoning. 

As was pointed out by MM. Eulenburg and Guttman ( Aertzl. Litera- 
turblatt, 1868, No. 12, quoted in Syd. Soc. Year-Book , 1868, p. 450), and 
subsequently by Professor Bamberger ( Wiener Med. Presse, Jan. 1872 ; 
Virchow's Archiv , June, 1872), phosphorus in a solution of a soluble salt 
of copper becomes immediately black, owing to the formation of a 
phosphide of the metal. Professor Bamberger ( loc. cit.) also asserts 
that, while this change is very rapid, that induced by turpentine is a 
slow one, and, from an elaborate series of experiments upon animals, 
concludes that copper is much the more valuable and certain antidote. 
In human poisoning, then, sulphate of copper should be given in dilute 
solution, three grains every five minutes until vomiting is induced. 
After this, if the French oil be accessible, it may be given freely in 
emulsion. Otherwise, sulphate of copper, with opium to restrain the 
emesis, should be administered in such doses as the stomach will retain. 
Sulphate or citrate of magnesium should be used as a quickly-acting 
purge, and symptoms as they arise should be judiciously treated. 

Match-makers and other artisans who are exposed by their occupa¬ 
tions to the fumes of phosphorus suffer from chronic poisoning, which, 
while in many cases it profoundly affects the vitality of the sufferer, is 
especially distinguished by the occurrence of necrosis of the upper or 
lower jaw. It has long been known that those artisans who have bad 
teeth are especially liable to be seriously affected, and the experiments 
of Wegner have demonstrated that the necrosis of the jaw is due to 
the local action of the vapor of phosphorus upon the part. He found 
that when rabbits were kept in an atmosphere full of the fumes of the 


496 


GENERAL REMEDIES. 


poison no necrosis ever occurred, unless, by means of an unsound tooth 
or an artificial wound, the atmosphere had access to the bone. If such 
access were, on the other hand, allowed to any bone of the body, peri¬ 
ostitis and subsequent necrosis resulted. Further, when rabbits re¬ 
ceived continuously small doses of the phosphorus by the mouth, no 
necrosis occurred even after wounds which laid bare the bones. As 
phosphorus-necrosis belongs to the province of the surgeon rather than 
of the physician, I shall not discuss it further here. 

Administration.— Phosphorus may be given in pill or in solution. 
The Oleum Phosphoratum, U.S., containing one per cent, by weight of 
phosphorus, may be given in doses of one to three minims in aroma¬ 
tized emulsion or in capsules. The Pilulce Phosphori , U.S., or officinal 
pills of phosphorus, contain one-hundredth of a grain each. In regard 
to the dose of phosjihorus, I have found that many stomachs will not 
bear more than the fiftieth or even the hundredth of a grain if given 
in the liquid form; but I have given as high as the twentieth of a grain 
of the solid drug. Dr. J. A. Thompson has used it in much larger doses 
(Practitioner , July, 1873), prescribing one-twelfth of a grain as an aver¬ 
age dose, and in one case having given as high as one-fourth of a grain 
every four hours without injury. On the other hand, Dr. Anstie has 
seen slight poisoning from three-fourths of a grain taken in small 
divided doses during seven days ( Practitioner , Aug. 1873). 

Zinci Phosphidum, U.S.— Phosphide of Zinc has been largely used, 
with asserted good results, as a substitute for phosphorus. According 
to the researches of Yigier (Bull. Therap., xc., Jan. 1876), it would 
seem that the phosphide yields its phosphorus within the economy, 
probably to form a phosphuretted hydrogen. He found that it killed 
rabbits more quickly than did a corresponding dose of phosphorus, and 
that both symptoms and lesions were identical in the two cases. The 
phosphide should be given in pill or granule. The dose may be con¬ 
sidered as from one-twentieth to one-twelfth of a grain. Professor 
Seguin recommends doses of from one-fourth to one-sixth of a grain. 


FAMILY III—ALTER ATI Y ES. 


There are employed by practitioners of medicine, to affect certain 
diseases most intimately connected with the processes of nutrition, 
various substances which do not, at least in the doses commonly used, 
produce any very obvious symptoms. These drugs may perhaps neither 
stimulate nor depress, so far as can be perceived, any function of the 
body; their action may be silent and imperceptible, their mode of in¬ 
fluence may be unknown; but their therapeutic effects are among the 
most assured of clinical facts. It is to medicines of this character that 
the name of Alteratives has been applied, because when administered 
they seem simply to alter morbid processes. 

Speculation has been rife as to the mode in which alteratives influ¬ 
ence the body; and as the accepted pathology has been humoralistic 
or otherwise, so has it been strenuously argued that they act upon the 
vital fluid, or upon the solids of the body. The term “ purifying of the 
blood” has been especially applied to their action, and is sufficiently 
suggestive of their function as viewed from the pathological stand¬ 
point of the old humoralist. What we know of the action of these 
medicines at present amounts to this, that they modify the nutritive 
processes of the body. As the physiologist has scarcely learned the 
alphabet of that part of his science which treats of the general nutri¬ 
tion, having no positive knowledge as to what is the real dominant force 
in the nutritive processes,—as the pathologist is completely baffled in 
attempting to find the essence, as it were, of the morbid processes 
which are successfully met by alteratives,—as he cannot point out to 
us what perverted functions underlie these diseases as their basis,— 
why should the therapeutist be expected to explain the rationale of his 
treatment ? The empirical facts of the clinical pathologist are met by 
the empirical facts of the clinical therapeutist. It is absurd to gaze 
into mid-air for the crowning spire before the foundation-stones of the 
temple are laid. 

To deny, as has been done, the existence or value of medicines of 
this class because we cannot tell why mercury relieves syphilis or why 
iodide of potassium cures rheumatism, is as absurd as to deny the ex¬ 
istence of the syphilitic and the rheumatic dyscrasia because we do 
not know their ultimate nature. Let us be content, until more light 
comes, to hold fast to the clinical facts, each believing for himself, if he 
choose, that alteratives alter nutrition by affecting the functions of the 

32 497 



498 


GENERAL REMEDIES. 


blood-making organs, or, if ho prefer, that they act by impressing the 
cells of the body directly; or, what is even more philosophical, each 
holding his mind free from belief, an unoccupied tablet on which the 
truth may readily be inscribed when it is discovered. 

ACIDUM ARSENIOSUM—ARSENIOUS ACID. U.S. 

T Yhite Arsenic, or Arsenic, as first prepared by sublimation from the 
ores, is in transparent masses, but on keeping becomes milk-white ex¬ 
ternally. It is soluble in water, has a vitreous fracture, is odorless, of 
a faint sweetish taste, and volatilizes without fusion “ at a temperature 
not exceeding 400° F.” When it is put upon red-hot iron it emits a 
garlicky odor, owing to its being first reduced to a metallic state and 
then volatilized. 

Physiological Action. —When applied to any part in a concen¬ 
trated form, arsenic is a very active escharotic, and even when very 
much diluted it is a severe irritant. When a single dose of just suffi¬ 
cient size to be felt is ingested, colicky pains, diarrhoea, and perhaps 
nausea result. After a very large toxic dose, in from one-quarter to 
three-quarters of an hour an intense burning pain is felt in the oesoph¬ 
agus and stomach, soon spreading to the whole belly, and often accom¬ 
panied by a sense of constriction at the throat, and an acrid, metallic 
taste. In a very short time violent vomiting and purging come on. 
The matters rejected are at first mucous, and variously colored by the 
contents of the primse viie; but they soon become bilious, and often 
yellowish or greenish, and finally serous, with mucoid flakes and a 
greater or less amount of blood. As the case progresses, the symptoms 
mentioned increase in intensity, and to them are soon added others of 
different nature. The thirst is excessive ; the urine is suppressed; the 
extremities are icy cold; the pulse is small, feeble, and-frequent; the 
rapid and labored respiration is very much embarrassed and painful 
from the abdominal tenderness; the surface is dark and cyanosed; 
violent cramps add their torture; exhaustion deepens into collapse; 
convulsions or coma ensue, and death occurs in from five to twenty 
hours. 

In another set of cases, when the dose has been smaller or the 
subject less susceptible, the termination is not reached so soon. After 
symptoms similar to but less violent than those just described have 
lasted from a few hours to one or two days, a remission occurs; the 
purging and vomiting grow less frequent, or perhaps intermit; even 
the abdominal tenderness may in great measure disappear; but the 
persistent thirst, cold extremities, and suppressed urine show that the 
danger is not overpast, and after a time the case puts on a more alarm¬ 
ing aspect. The belly becomes very tumid, the abdominal pain more 
severe, difficulty of respiration develops itself, the face is swollen and 
cyanosed, nervous symptoms, tremblings, cramps, and convulsions ap¬ 
pear, and finally an icy coldness pervades the frame, and death occurs 


ALTERATIVES. 


499 


in from two to six days. The mind is generally clear to the last. If 
the patient survive long enough, an eruption very frequently appears, 
sometimes as early as the second day, sometimes not until the fifth. 
Its character is various: thus, it may be petechial, urticaria-like, pap¬ 
ular, vesicular, or pustular ( Histoire des Eruptions arsenicales, par Dr. 
Imbert-Gourbeyre, Moniteur des Hopitaux, 1857). 

Such are the ordinary symptoms of arsenical poisoning; but anom¬ 
alous cases are not rare. Sometimes profound and rapid collapse, 
without abdominal pain, has occurred; in other cases heavy sleep, 
deepening into coma, is said to have been the most marked symptom. 
Sometimes arsenical poisoning very closely resembles cholera, and it 
has been mistaken for it not only in life, but also after death, on the 
post-mortem table ( Virchow's Archiv, 1870, Bd. 1. p. 456). 

When arsenical poisoning is not fatal, the convalescence is apt to be 
slow, and interrupted by various disorders. Prominent among these 
are affections of the alimentary canal, due to the structural changes 
produced by the poison. Nervous symptoms are common, and may 
affect the motor or sensory sphere separately or combined. In some 
cases they have developed very suddenly (W. I r . Med. Journ ., 1850, 177). 
I have seen anaesthesia of the feet as the only symptom; motor paral¬ 
ysis may exist alone, but it is usually accompanied by anaesthesia, 
hyperaesthesia, loss of temperature-sense, great feeling of coldness, or 
other disorder of sensation, and not rarely excessive pain, which may 
be aching or lancinating. Occasionally there are severe cramps. The 
normal sensibility is usually regained before normal motility. Of one 
hundred cases of arsenical paralysis collected by Imbert-Gourbeyre 
(Des Suites de V Empoisonnement arsenic ale, Paris, 1881), in more than 
half all the extremities were affected; about one-fourth were para¬ 
plegic ; in the remainder there was hemiplegia or local palsy. Most 
frequently the paralysis was not pronounced above the elbow or knee. 
The lamed muscles are usually sensitive to pressure (C. Gerhard, 
Sitzungsb. Physik. Med. Gesellsch. Wurzburg , April, 1882),* and undergo 
rapid atrophy, losing very early their electro-muscular contractility, or 
presenting the “ reactions of degeneration.” This poisoning resembles 
sub-acute poliomyelitis, but differs in the frequency of pain and other 
sensory disturbances, and in the tendency towards more or less com¬ 
plete recovery. I have seen recovery when the muscular remnants on 
the wasted limbs had for many months been unable to respond to any 
form of galvanic current; and out of Imbert-Gourbeyre’s one hundred 
cases all got well except three. Dr. N. Popow found, in dogs killed in 
a few hours by a dose of arsenic, the spinal cord inflamed; after slower 
poisoning there were masses of “exudate” in the neighborhood of the 


* Consult also Renner, Ueber ein Fall von chron. Arsenvergift., WUrzburg, 1876; W. P. 
McIntosh, N. Y. Med. Record, Feb. 1885, 145; Seguin, Journ. Nerv. and Ment. Disease*, 
Oct. 1882, vii. 665; C. K. Mills, Trans. College of Physicians of Philadelphia, 3d series, vi.; 
Archives de Physiol. Norm, et Path., 1884, iv. 



500 


GENERAL REMEDIES. 


blood-vessels, and in very protracted cases the walls of the spinal arte¬ 
rioles were found to be thickened and the large cells of the gray matter 
profoundly altered. The protoplasm first became opaque and granular; 
the nuclei grew fainter and fainter, and finally disappeared; vacu¬ 
oles appeared, and encroached more and more on the shrunken body of 
the cell, which finally disappeared ( Virchow's Archie , Bd. xciii.). These 
experiments certainly show that arsenic may cause lesions of the spinal 
cord; but the sensory disturbance usually present in nervous arsenical 
poisoning, and especially the tenderness of the nerve-trunks, which has 
been very pronounced in the cases that I have seen, prove that a wide¬ 
spread multiple neuritis is the common lesion. In some of these cases 
trophic changes are pronounced: thus, I have seen a growth of hair 
several inches long cover the wasted limbs. If in any case of arsenical 
paralysis there were no sensory disturbance, the probabilities would be 
very strong that the lesion was a toxic poliomyelitis. 

The most obvious lesions found after death from acute poisoning by 
arsenic are in the stomach and bowels, even when the poison has found 
entrance into the system through other channels. The gastric mucous 
membrane is usually swollen, maculated with patches of a deep-crimson 
or more commonly brownish-red color, and is often softened and cov¬ 
ered with a diphtheritic exudation, but is rarely ulcerated. Perfora¬ 
tion is exceedingly uncommon. The mucous membrane of the upper 
part of the small intestine, and sometimes of the whole of it, is in a 
condition similar to that of the stomach. In some cases the lesions very 
closely resemble those of cholera, as was first pointed out by Professor 
Yirchow ( Virchow's Archie , Bd. xlvii.). In the microscopic examina¬ 
tion of a cadaver whose bowels were filled with a “rice-water” fluid, 
that observer found in the intestinal contents epithelial flakes, and the 
fungus described by Klobs as peculiar to, and, indeed, the cause of, 
cholera. The epithelial cells of the mucous membrane were choked 
with granules, and many of them in an advanced stage of fatty de¬ 
generation ; the interstitial tissue was full of large round granulated 
cells; the solitary glands and Peyer’s patches were very much swollen. 
These facts have been confirmed by Dr. Hoffmann ( Virchow's Archie, 
Bd. 1. p. 456). The gastro-intestinal lesions produced by arsenic are 
not due solely or largely to its immediate local effect, since they occur 
equally when the animal is killed by injection of the poison into a vein. 
The local influence of the drug is, however, probably not altogether 
lost, since Unterberger ( loc. cit.) found that a larger dose was required 
to kill an animal by venous injection than by exhibition by the mouth. 

There is usually in acute arsenical poisoning a wide-spread granular 
or fatty degeneration of the tissues. M. Karajau (Tardieu, Sur I'Empoi- 
sonnement, p. 335) reports a case, which had been mistaken during life 
for acute atrophy of the liver; Pr. Grohl and Fr. Mosler ( Virchow's 
Archie , Bd. xxxiv. p. 213) one in which they found fatty or granular 
metamorphosis of the glands and epithelium of the stomach and intes- 


ALTERATIVES. 


501 


tines, of the cardiac muscle, of the diaphragm, of the cortical portions 
of the kidney, and, to a slight extent, of some of the voluntary mus¬ 
cles; Dr. 1.1. Pinkham ( Boston Med. and Surg. Journ., 1878, 358) one in 
which the liver, kidneys, and epithelial lining of the peptic glands 
were almost destroyed; similar lesions have also been reported by M. 
V. Cornil (Soc. Med. des Hop. de Paris , xvii. 379) and by Dr. Fereol 
(Ibid., p. 321). 

The absolute demonstration of the degeneration pi’oduced by arsenic 
was, however, made by Dr. Salkowsky ( Virchow's Archiv, Bd. xxxiv. p. 
77), of Moscow, who was also the first to point it out. In his numerous 
experiments upon rabbits he found that when the animals were poisoned 
by a small dose of arsenic, so as to live from three to six days, the liver 
was much enlarged and very fatty,—indeed, contained more fat than 
the “ phosphorus-liver.” On microscopical examination, the cells on the 
exterior of each acinus were seen to be natural; those in the centre 
in the most advanced stages of degeneration. The kidneys were simi¬ 
larly affected,—their tubes choked up with fat-globules, their epithe¬ 
lium almost completely destroyed. The muscles of the heart and dia¬ 
phragm were almost equally compromised. Dr. Salkowsky also noted 
that early in both arsenical and antimonial poisoning the glycogenic 
function of the liver is abolished.* In frogs poisoned with arsenic 
the epidermis peels off from the derm, as first noted by Ringer and 
Murrell, and Emily A. Nunn has found that the influence of the poison 
is first manifested in the under portion of the epidermis, the degen¬ 
eration progressing from the derm outwards ( Journal of Physiology, 
i. 247). 

As arsenic is never used in medicine for an acute effect, the chief 
interest to the therapeutist centres around its physiological action 
when given in small doses; yet it seems necessary here to take cogni¬ 
zance of the physiological action of large amounts of the poison.f 

Nervous and Muscular Systems. —The symptoms of arsenical poison¬ 
ing in man show that the drug has a marked influence upon the ner¬ 
vous system. Dr. W. Sklarek, of Berlin ( Reichert's Archiv , 1866), has 
found that the arseniates of potassium and of sodium had exactly the 
same effect as arsenic itself upon frogs. Within five minutes after 
the injection of one-fourth to two c.c. of a two-per-cent, solution of 
arsenious acid, or of the arseniate of sodium or of potassium, all volun- 


* For a spectroscopic study of the effect of arsenic upon the coloring-matter of the blood, 
see Centralblatt, 1868, p. 609. It is interesting here to note that arsenic, antimony, phos¬ 
phorus, and ammonia act very similarly, if not identically, upon the blood. 

f The theory of Biuz and Schulz, that arsenious acid acts by taking from protoplasm 
oxygen, so as to be converted into arsenic acid, and afterwards yields up this oxygen to 
oxidize the protoplasm, and then repeats the process, seems to me so ill supported that the 
reader in regard to it is simply referred to Arch. f. Exper. Path. u. Pharm., xi. 213, xiv. 249; 
also Brit. Med. Journ., 1882, ii. 1135. Dogiel’s theory, that arsenic unites chemically with 
the albuminous principle, is more probable. See Trane. International Congress, 1884, i. 
p. 134. 



502 


GENERAL REMEDIES. 


tary movement ceased in the frog; although when the animal was laid 
upon his back he struggled very actively to recover his position. At 
this time, however, all sensibility to chemical and mechanical irritants 
was lost, cutting, burning, or corroding failing to elicit any response. 
That the motor system was not at fault was shown by the active move¬ 
ments when the frog was placed upon his back, as well as by the results 
of electrical stimulation of the nerves. The paralysis or quietness must 
have been due to an abolition of sensation. That this was spinal, and 
not peripheral, was proved by the circumstance that tying the iliac 
artery upon one side before the administration of the poison had no 
effect in preserving sensibility in the protected leg. The only explana¬ 
tion of the struggles of the frog to recover his position after poisoning 
is to be found in his having been influenced through vision, or else in 
the theory that the muscular sense is distinct from that of common 
sensibility and is not affected by arsenic. The researches of Ringer 
and Murrell (Journal of Physiology, i. 217) upon frogs have given very 
different results from those just described, they finding that the symp¬ 
toms of poisoning came only after the lapse of some hours, and that 
paralysis of voluntary motion preceded that of sensation and reflex 
action. Drs. Ringer and Murrell suggest that these differences of result 
depend upon the time of year at which the frog was experimented on. 
There is accord between the experimenters in regard to the cause of the 
final paralysis, all finding that it is produced by a direct action of the 
arsenic upon the nerve-centres. Ringer and Murrell have also shown, 
however, that the nerves and muscles do not entirely escape the poison, 
which seems to be more or less toxic to all highly-organized tissues. 

Circulation .—Upon the heart of the frog Dr. Sklarek found that 
arsenic exerts a very powerful influence, lessening the rapidity and 
force of the beat, and finally arresting «the contraction. That this 
cardiac action of arsenic is direct was shown by the exact similarity of 
the phenomena produced by the application of arsenic to the heart cut 
out of the body. The arrest was never instantaneous, but always pre¬ 
ceded by slowing of the beat; and after movement had ceased, galvanic 
or mechanical irritation caused imperfect systolic movements. In no 
ease did Dr. Sklarek observe any signs of functional excitement pre¬ 
ceding the development of the cardiac or motor paralysis. 

Dr. Sklarek also found that in arsenical poisoning in the cat there 
is great reduction in the force and frequency of the heart’s pulsations. 
Recently the effect of the poison upon the circulation of mammals has 
been elaborately investigated by Dr. S. Unterberger (Archiv f. Exper. 
Path. u. Pharm., Bd. ii.). Like Cunza, he found that in arsenical poi¬ 
soning the heart persists in its movements after the cessation of respi¬ 
ration. Immediately after an injection of the poison in cats and dogs, 
both the pulse-rate and the arterial pressure fall enormously, and if the 
dose has been sufficient they never recover themselves. Dr. Unterberger 
did not make out the cause of the fall of the pulse-rate, but the experi- 


ALTERATIVES. 


50 ) 


ments of Sklarek, already mentioned, indicate that it is due to a direct 
action on the heart. 

The depression of the arterial pressure was shown by Unterberger 
to be largely due to vaso-motor paralysis, for in an animal under the 
influence of the poison neither galvanization of a sensory nerve nor of 
the vaso-motor centre in the upper cord had any influence upon the 
force of the blood-current. Galvanization of the splanchnics had no 
effect upon the arterial pressure,—apparently showing that the vaso¬ 
motor palsy was peripheral; but Dr. Unterberger found, to his astonish¬ 
ment, that stimulation of the cervical sympathetics had the usual effect 
upon the vessels of the rabbit’s ear. Supposing these observations to 
be correct, there are only two seemingly possible methods of reconciling 
them: either the drug acts upon the peripheral vaso-motor nerves in 
the abdomen and not upon the same nerves in the neck, or else there 
is during arsenical poisoning such depression of the power of the cardiac 
muscle that narrowing of the blood-path does not have the usual effect. 
Dr. Unterberger found that compression of the abdominal aorta was 
followed by a great rise of pressure, and therefore he believes that the 
heart in arsenical poisoning has not' lost its power. Some complicated 
transfusion experiments which he made indicated differently, so that 
while his proposition that arsenic paralyzes the peripheral vaso-motor 
nerves of the abdomen and not those of the head may be considered 
probable, it certainly is not proved. It would be a very easy matter to 
decide the question by dividing the splanchnic nerves in a poisoned 
animal: if the reduction of the arterial pressure be really due to an 
abdominal vaso-motor paresis, section of the splanchnic should have 
no effect on it. There appears to be no doubt that the cardiac muscle 
is more or less weakened by the poison. 

Action of Small Doses. —Minute quantities of arsenic may be given 
for a long time without producing any perceptible effect, unless it be 
a sharpening of the appetite, due to the local action on the stomach. 
When the dose is increased, more active manifestations of gastric irri¬ 
tation may appear, such as loss of appetite, nausea, abdominal pain or 
uneasiness, diarrhoea, and perhaps sympathetic headache. By the use 
of frequent small doses these symptoms may be generally avoided, and 
what may be termed the constitutional action of arsenic be obtained. 
The first sign of this is generally a puffiness about the eyes, at first 
visible only in the early mornings, but soon increasing into decided 
oedema, which after a time may lose its local character and the patient 
be involved in general anasarca. This anasarca, as was, I believe, first 
pointed out by Dr. S. Weir Mitchell ( New York Medical Journal , vol. i.), 
may or may not be preceded or accompanied by the presence of albu¬ 
men and of tube-casts in the urine. Beyond the production of the 
symptoms spoken of, arsenic should never be employed in medicine. 

Unfortunately, owing to the frequent use of the metal in the arts, 
chronic arsenical poisoning is by no means uncommon. Although the 


504 


GENERAL REMEDIES. 


symptoms vary a good deal and may be very obscure, yet in almost 
every case they are such as should at once awaken suspicion. They 
were summed up by the late Professor Taylor as follows: “ Dryness 
and irritation of the throat, irritation of the mucous membranes of the 
eyes and nostrils, dry cough, languor, headache, loss of appetite, nausea, 
colicky pains, numbness, cramp, irritability of the bowels, attended with 
mucous discharges, great prostration of strength, a feverish condition, 
and wasting of the body.” It is very evident that the symptoms of 
irritation of the respiratory mucous membrane are largely, if not en¬ 
tirely, due to the local action of the arsenic, since the poison finds ac¬ 
cess to the system through the respiratory organs. The constitutional 
troubles most uniformly present in these cases are weakness and emaci¬ 
ation, often accompanied by more decided nervous manifestations than 
the picture drawn by Dr. Taylor would suggest: great depression of 
spirits and irritability of disposition, sleeplessness, giddiness, headache 
with a feeling of constriction in the forehead, numbness in the extremi¬ 
ties, muscular tremors or stiffness, vertigo, and even convulsions and 
paralysis, are very common. Indeed, in some cases these nervous 
symptoms constitute the chief if not the sole features. (See Deutsche 
Klinik, 1874, No. 31; also Schmidt's Jahrb., Bd. clxv. p. 233.) 

Dr. Kirchgasser, as the result of very large experience, asserts that 
the most characteristic phenomena of chronic arsenicism are a brown 
pigment-deposit in the skin of the face, inflammatory affection of the 
eyelids, and the disturbances of sensibility and motion, which affect 
most frequently the lower extremities, together with scalding during 
urination. Out of eight cases, he found arsenic in the urine in six 
( Berlin. Centralblatt, p. 574, 1868). 

Seemingly opposed to this common experience is the asserted “ ar¬ 
senic-eating” of the peasants of Styria. It*is stated by sbme that the 
arsenic is taken by the young girls to beautify their complexion and to 
enhance their charms; by others, that the object sought to be attained 
is protection against arsenical fumes by those engaged in the manu¬ 
facture of the metal, and the increase of the powers of endurance and 
of the “wind” in huntsmen and others who do a great deal of mountain¬ 
climbing. The habit is said not to be detrimental to life. Indeed, the 
toxiphagi are asserted to be remarkably long-lived people. In regard 
to the dose, three grains are said to be taken as a commencement, and 
to be increased to thirty! Originally affirmed by Vogt ( Lehrbuch der 
Pharmacodynamik, Aufl. iii. Bd. i.), the existence of this practice has 
been especially asserted by Tscbudi, and more recently by Chas. Heiscli 
( Pharm . Journ. Trans., 1859 and 1860, vol. i. p. 556). 

Notwithstanding the assertion of Ileisch, the existence of the prac¬ 
tice was not credited (see British and Foreign Med.-Chir. Review, vol. 
xxix. p. 144). but in 1864 Dr. C. Maclagan ( Edinb. Med. Journ., 1864, 
p. 203) visited Styria, saw several arsenic-eaters, administered to one 
of them five grains of the substance at a dose without ill effects, and 


ALTERATIVES. 


505 


found the poison in the urine. lie also analyzed the material which 
the men habitually took, and found it to be arsenic. 

An unsigned (editorial?) communication in the Edinb. Med. and 
Surg. Journ. (1871, vol. xvi. p. 569) further asserts that a royal com¬ 
mission has examined into the subject, and that their report indicates 
that the practice exists, but that it has been grossly exaggerated. 
They affirm that arsenic-eating is practised chiefly in the northern and 
northwestern parts of Styria; that the white arsenic is preferred, the 
yellow commercial article being sometimes taken, the native red arsenic, 
or orpiment, very rarely; that the commencing dose is about 0.22 grain, 
which is very slowly increased to 0.62 grain avoirdupois. The “ratsbane- 
eaters” almost all belong to the lower classes, and are said to be gener¬ 
ally strong and healthy persons, courageous, pugnacious, and of strong 
sexual disposition. These statements are in accord with those of Dr. 
Maclagan, and must, I think, be accepted as true. Dr. Maclagan also 
says that in one case of suspected poisoning in Styria the prisoner was 
acquitted on the ground that the deceased was an arsenic-eater. 

Of especial interest in connection with arsenic-eating is the verity 
or non-verity of the asserted effect of the drug upon tissue-changes. 
Schmidt and Sturzwage believe that it has such action in a very marked 
degree, because in their experiments upon rabbits they found a decided 
diminution in the excretion of carbonic acid and of urea during the 
use of minute doses of the poison. Fokker ( Schmidt's Jahrb ., clviii. 13), 
however, was unable to perceive in three experiments that daily doses 
of from .15 to .075 grain of arsenic to a dog had any effect upon the 
elimination of urea, and Kossell and Gaethgens, in two experiments, 
have noted a very decided increase of the elimination of urea produced 
by toxic doses of arsenic in the dog (Arch. f. Exper. Pathol, u. Pharrn ., 
Bd. v. p. 133, also Centralbl. f. Med. Wissen., 1875, 530; 1876, 833). The 
recent experiments of Chittenden and Cummins (Stud. Labor. Physiol. 
Chem. Yale Univ., vol. ii.) are in accord with the early results of Stiirz- 
wage, as they found that in the case of rabbits arsenious acid has a 
tendency to diminish the elimination of carbonic acid. The evidence 
which we have at present is not sufficient to warrant a positive opinion, 
but it indicates that small doses of arsenic check tissue-change and de¬ 
crease nitrogenous elimination , while large toxic doses have the opposite 
effect. 

When arsenic is administered in small repeated doses, it may act as 
a tonic, by slightly irritating the stomach and thereby provoking an 
appetite; and in certain cachexias it increases the muscular strength 
and the general vigor. The history of arsenic-eating indicates that the 
drug has some positive tonic influence over nutrition; and although the 
amelioration, the increase of strength and blood, by its use in cachexias 
may be due to an indirect action of the drug,—to a removal or over¬ 
coming of the morbific agent of the disease, and a consequent allowing 
of the recuperative powers of the system to assert themselves,—there 


506 


GENERAL REMEDIES. 


is much reason for believing that it does act as a direct stimulant to 
nutrition. All that we know of the elfect of arsenic upon the system 
throws only enough light on its therapeutic action to enable us to class 
it as an alterative,—a modifier and often an improver of nutrition. 

Elimination. —There is abundant proof of the absorption, and no 
less of the elimination, of arsenic. Indeed, the latter appears to take 
place with exceptional rapidity. Thus, MM. Flandin and Danger (Huse- 
mann, Toxicologie , p. 823) failed, three days after the last dose, to 
detect it in the bodies of animals to which fifteen grains had been 
given daily; and in a child killed in two days by an arsenical pigment, 
none of the metal could be found in the body ( British and Foreign 
Med.-Chir. Review , 1870, vol. xlv.). In the great majority of instances, 
however, there is no trouble in finding arsenic in the bodies of those 
poisoned by it, and Steinhauser reports a case in which it was found in 
the remnants of a corpse that had been buried for twenty-two years 
(Berlin. Centralblatt, 1868, p. 160). The principal channel of escape is the 
kidneys; but elimination also takes place through the mucous membrane 
of the alimentary canal, through the skin, and even in the saliva and 
the tears. M. G-. Bouchet and Lewald in independent researches found 
arsenic in notable quantities in the milk of nursing women to whom it 
had been given. (See American Practitioner , 1887.) Unterberger has 
detected it in the alimentary canal of animals poisoned by injection 
into the vein. M. Chatin has found it in the serosity of a blister, 
Bergeron and Lemaitre in the sweat ( British and Foreign Med.-Chir. 
Review , vol. xlviii., 1871), and Taylor ( Guy's Hospital Rep., vol. x. 3d 
series, 1864, p. 227) in the contents of the stomach of a child poisoned 
by its application to the scalp.* 

Especially in connection with the therapeutic use of arsenic in 
malarial fever, some interest attaches to the effect of the drug upon 
the lower organisms and fermentations. The subject has been partially 
investigated by Johannsohn (Arch. f. Exper. Path. u. Pharm., Bd. ii. p. 
106), who concludes that the poison produces a peculiar degeneration 
of the yeast-plant, but actually increases the production of bacteria in 
yeast. When small amounts of arsenic were added to yeast and syrup, 
the fermentative process was at first very much checked, but not abso¬ 
lutely prevented. After a time the process went on faster again. In 
urine Johannsohn found that the poison hindered the production of 
Micrococcus urea, but actually favored that of other fungi. In the 
lactic fermentation the growth of the peculiar fungi was checked, while 
that of Mucor mucedo was favored. The fact that arsenic acts slowly 
upon the yeast has been confirmed by Schaefer and Boehm (Arbeiten 
Physiol. Inst. Wurzburger Hochschule, 1873, p. 173). Both Johannsohn 


* Various observers have endeavored to determine which tissues contain most arsenio 
after death from the poison, with varying results. Consult Arch, de Physiol. Norm, et Path., 
1875, ii. 653; Chem. Centralblatt, 1879, 602; Arch./. Exper. Path. u. Pharm., xiii. 257; The 
Chemist and Druggist, xxi., 1879, 381; Comptes-llendus, 1879, lxxxviii. 1212. 



ALTERATIVES. 


507 


and Schaefer and Boehm have found that arsenic exerts no influence 
upon non-organized ferments, either vegetable or animal, such as amyg- 
dalin, pepsin, pancreatin, etc. 

Therapeutics.— Our knowledge of the value of arsenic in disease 
rests solely upon clinical observation, which has abundantly established 
its use in certain very diverse affections. Chief among these is chronic 
malarial dyscrasia. No one would at present think of employing it in 
acute remittent fever, or even in acute intermittent, unless under very 
peculiar circumstances. It is in those cases which have resisted quinine, 
in which the paroxysms have become irregular, returning at long or ir¬ 
regular intervals, and in which the ansemia and the general nutritive 
disturbance are even more prominent than the febrile disorder, that 
arsenic is especially valuable. In these cases it should be administered 
with sufficient boldness, very generally in conjunction with iron. Pro¬ 
fessor George B. Wood recommends that the first doses should be as 
large as the system will endure, so as to make a decided impression at 
once. When the ague-paroxysms are frequent, it is perhaps well to 
employ this plan; but when it is rather the cachexia than the active 
disorder that is to be combated, it is preferable to commence with 
small doses and to increase them until some constitutional symptom 
is produced. In ordinary intermittents, after the paroxysms have been 
broken up by quinine it is very well to place the patient upon a prep, 
aration of arsenic and iron, as a prophylactic against their return. 
When, in ordinary intermittent fever, for any cause quinine cannot be 
administered, arsenic may be employed. In these cases, as already in¬ 
timated, the first doses should be large, so as to make an immediate im¬ 
pression ; from five to ten minims of Fowler’s solution, properly diluted, 
may be given every two or three hours until some decided symptom is 
produced. When the stomach refuses the remedy, it has been recom¬ 
mended by Boudin to give it by the rectum, which he affirms will often 
bear even a grain of the acid. Not more than a third of this amount 
should, however, be used as a commencing dose. In malarial intermit¬ 
tent neuralgia, arsenic may be employed as a very useful adjuvant to 
the antiperiodic alkaloids. Dr. K. M. Downie calls attention (. Indian 
Medical Journal, 1872) to the value of arsenic as a ‘prophylactic against 
malaria. His trials were not numerous enough to be conclusive, but so 
far as they go they indicate that arsenic is even superior to quinine. 
Decently attention has been drawn to the great value of arsenic in 
lymphatic tumors, especially in the affection known as malignant lym¬ 
phoma ( Wien. Med. Wochenschrift, 1871; Arch. f. Klin. Chir., xviii.; 
Strieker's Jahrb., 1877). Advantage is said to be sometimes derived 
from injections of the remedy into the growth. 

Having had very little experience myself in the use of arsenic in 
skin-disease, Dr. Louis A. Duhring, Professor of Dermatology in the 
University Hospital, has kindly furnished me with the following: 

“ As is well known, arsenic has long been used and held in high esteem 


508 


GENERAL REMEDIES. 


as a remedy in the treatment of cutaneous diseases. It is proper to 
state, however, that at the present day there exists a great diversity 
of opinion concerning its actual value as a therapeutic agent against 
this class of diseases. Certain dermatologists claim to derive marked 
good from its employment in quite a large number of affections, while 
others of equal experience are inclined to place but little reliance upon 
its curative powers. Without entering at all into this discussion, it 
may be unhesitatingly said that it is a remedy of real worth and service 
in several very important cutaneous diseases, and that it may be com¬ 
bined with other remedies and used with good result in certain other 
diseases of the skin, acting in these cases as a general tonic. It is the 
dermatologist’s most valuable internal remedy in a large number of 
cases. But it must be skilfully employed, and the cases, moreover, must 
be selected, if we would expect satisfactory results. To say that arsenic 
is of use in diseases of the skin viewed collectively, is an assertion so 
vague as to be of no practical value. Not only is it necessary to specify 
the disease, but it is even important to designate the particular stage, 
if we would employ the remedy successfully. 

“ Arsenic exerts its influence chiefly upon the epidermis. Hence it is 
found that diseases affecting the more superficial strata of the skin are 
most amenable to its influence. It possesses little or no effect upon the 
diseases which have their seat in the deeper structures. 

“ Its action upon the skin is slow, weeks and months being requi¬ 
site to produce the desired result. Improvement once obtained, it 
is usually expedient to allow the patient to continue the use of the 
remedy for some weeks after all symptoms of the disease have dis¬ 
appeared. 

“ Arsenic should never be employed in the acute, inflammatory stage 
of any disease of the skin. It should not be prescribed when there is 
great heat, burning, intense itching, or rapid cell-change. It not only 
is of no benefit at this stage, but is in most cases positively injurious, 
tending to augment the activity of the morbid process. It stimulates 
the rete into action when rest is most needed. Its administration should 
be withheld until the acute symptoms have subsided. 

“ Of many of the dissimilar diseases in which arsenic has been em¬ 
ployed, both with and without reputed success, no mention need here 
be made. It will suffice for the purpose in hand to refer to those affec¬ 
tions which it is generally conceded are more or less favorably influ¬ 
enced. It is unquestionably of great value in psoriasis. But it is not 
of benefit in every case, nor should it be prescribed for all forms, or in 
all stages, of this disease. When the process is very active, attended 
with intense hyperaemia, arsenic, as a rule, only aggravates the inflam¬ 
matory condition. The more active the cell-proliferation, the less prob¬ 
ability is there of its being of benefit. On the other hand, the more 
indolent and sluggish the disease, the greater the chances for improve¬ 
ment. It should be withheld until the process has fairly settled in its 


ALTEEATIVES. 


509 


career. In cases of psoriasis of long standing, which manifest little 
disposition to undergo change, it is particularly useful. 

“ It is of undoubted service in certain varieties of eczema , especially 
in the chronic squamous and papular varieties; also where the ele¬ 
mentary lesions are but ill defined; and, finally, where the disease is 
unusually superficially seated, and where there is only slight infiltra¬ 
tion of the skin. Certain forms of persistent localized papular and 
vesicular eczema, having a marked tendency to recur, as, for example, 
of the fingers, also often yield readily to arsenic. It should, of course, 
be avoided in acute eczema. 

“ Pemphigus is decidedly influenced, and often permanently relieved, 
by its use. It is our most reliable remedy for this disease. Here, as in 
other conditions, the older the process the more likely are we to obtain 
favorable results. In lichen planus and in lichen ruber it is employed 
with great advantage. Prescribed in minute doses, as a tonic, it may 
sometimes be given with benefit in chronic urticaria. 

“ It is likewise of value in certain varieties of acne. Before pre¬ 
scribing it, however, the digestive tract should be carefully looked into, 
and, if disordered in the least degree, it should first be rectified. The 
same remark holds good for its use in all diseases of the skin. Taken 
for a considerable time, several months, it often exerts a marked in¬ 
fluence upon the small pustular and papular forms of acne, and also in 
those cases where there is an accompanying erythematous rosacea. 

“ The two preparations of arsenic which it is, as a rule, advisable to 
employ are arsenious acid and liquor potassii arsenitis. The latter will 
be found the more desirable form for ordinary use. Arsenious acid is 
given in pill form, with sugar of milk, or combined with a grain each 
of black pepper and powdered liquorice, constituting the compound 
known as the Asiatic pill, which may be prescribed in various strengths, 
suitable to the case. The liquor potassii arsenitis is best given with 
water or combined with a bitter tincture or infusion; it is also well 
borne combined with the wine of iron. The average dose suitable to 
the majority of individuals is three minims. Smaller doses, one or two 
minims thrice daily, are often demanded, and in many cases are found 
to be much more beneficial than larger doses. On the other hand, four, 
six, or eight minims will not infrequently be tolerated, and occasion¬ 
ally even larger doses; but out of a number of patients it will be found 
that but few can take more than three or four minims for any length 
of time without derangement of the system. Arsenic should always 
be taken either with the food or directly afterwards.” 

In certain nervous affections arsenic acts very favorably, in some 
unknown way. It is especiall} r in chorea that it has acquired a deserved 
reputation. In this affection iron and other tonics are generally indi¬ 
cated, and may be given consentaneously with the arsenic. It is best, 
however, to administer the latter separately, as the dose must be steadily 


510 


GENERAL REMEDIES. 


increased until oedema or other manifestations betray its decided action. 
Arsenic has also been recommended in whooping-cough, but is at present 
very rarely, if ever, used. In ordinary non-malarial neuralgia it may 
be tried, and is sometimes serviceable; in simple gastralgia , or gastric 
neuralgia, it has been especially recommended. 

Arsenic is employed sometimes with advantage in asthma , and may 
be given by the stomach, but is perhaps more useful when inhaled. 
The following formula has been long used in the Philadelphia Hospital. 
The prepared paper is rolled into cigarettes, one of which is smoked two 
or three times a day, until relief is afforded or some giddiness produced : 

Charta Arsenicalis Composita ( Compound Arsenical Paper). R — 
Belladonnae fol., gr. xcvi; Hyoscyami fob, Stramonii fob, aa gr. xlviii; 
Extr. opii, gr. iv; Tabaci, gr. lxxx; Aquae, Oj; M., ft. sob et add. Potas. 
nit., gr. clx; Potas. arsenit., gr. cccxx. Saturate bibulous paper and dry 
for use. 

Arsenic is of value in those forms of chronic rheumatism in which 
iodide of potassium is commonly employed. It is often advantageous 
to alternate, administering one of these alteratives for three or four 
weeks, and then the other for the same length of time. In rheumatic 
gout, or rheumatoid arthritis , it has been highly extolled, but in my 
experience has furnished no better results than other remedies. It 
should, however, always be tried in this most obstinate disorder. 

There have been quite a number of cases reported in which an 
outbreak of herpes zoster has occurred during the long-continued use 
of arsenic, and it seems as though the arsenic was the cause of the 
eruption. (For paper, giving cases and bibliography, by O. Julius- 
burger, see Vierteljahr. f. Dermatol., Wien, xi. 97.) 

Toxicology. —Sufficient has already been said concerning the symp¬ 
toms of both acute and chronic arsenical poisoning. No mention has, 
however, been made of the peculiar local affections produced in the 
hands of those artisans who work with the preparations of arsenic. 
Ulcers about the roots of the nails are generally the first trouble in 
these cases, but after a time eczematous or papular eruptions appear, 
and even subdermal erysipelatous inflammation is developed. Very 
commonly to these local symptoms are added, after a time, the usual 
phenomena of chronic arsenical poisoning. 

In the arts, preparations of arsenic are largely used as pigments ;* 
and, excepting the manufacturers of arsenic, it is almost exclusively 
those who are accidentally exposed to the deleterious influence of these 
pigments that suffer from chronic arsenical poisoning. The poison¬ 
ous colors are of various hues, and, being very cheap, and remark¬ 
able for their purity of tone and their permanence under exposure to 

* For an excellent report upon this subject, see Report of the State Board of Health of 
Massachusetts, Jan. 1872, where it is stated that from five hundred to seven hundred tons of 
arsenical pigment were manufactured in 1862 in England alone. Fatal chronic arsenical 
poisoning from working in aniline dyes is reported in Strieker’s Jahrb., 1877, 501. 



ALTERATIVES. 


511 


light, are much used by paper-makers. Scheeles Green —the arsenite 
of copper—contains fifty-five per cent., by weight, of arsenious acid; 
and Schweinfurt Green —the aceto-arsenite—fifty-eight per cent. Paper 
coated with them has been largely used not only as hangings, but even 
as wrappings for confectionery and other edibles. Sweetmeats have 
been colored with them; pasteboard boxes, artificial flowers, tarlatan 
dresses, shelves in groceries, walls of dwellings, toys of children, and 
various other articles, have been made the vehicles of death, so that 
hundreds of eases of poisoning more or less severe have resulted from 
the use of these pigments, which ought to be banished by the strictest 
laws. In most cases it is probably the minute dust, which is sepa¬ 
rated mechanically and diffused through the room, that produces the 
fatal result; but poisoning has occurred when the arsenical paper was 
covered over with another paper. Dr. Hambers has made elaborate 
chemical researches upon the air of these apartments, and believes 
that he has demonstrated that some arsenic escapes in the form of 
arseniuretted hydrogen. Not rarely the poison has been taken directly 
into the stomach, especially by children. 

The time at which death occurs, as well as the fatal dose of arsenic, 
varies very much. Death usually results in from eighteen hours to 
three days; but Taylor reports a case in which it occurred with tetanic 
symptoms in twenty minutes, and life has been protracted until the 
sixteenth or even the twentieth day. Dr. W. C. Jackson ( Amer. Journ. 
Med. Sci., July, 1858) records a case of recovery, under the early use 
of emetics, after an estimated dose of two ounces had been taken; and 
Dr. E. D. Mackenzie gives an account ( Indian Med. Gaz ., 1872) of a 
man who swallowed an unknown quantity of arsenic in lumps, and 
received no treatment for sixteen hours, yet recovered after passing 
per anum one hundred and five grains of arsenic in two masses. On 
the other hand, death has resulted from the use of very small amounts. 
Dr. Taylor asserts that the smallest fatal dose hitherto recorded is two 
grains. Dr. Lachese (Ann. d'Hyg. et de Med. Legale , 1834, le ser., t. 
xvii.) affirms that six milligrammes (0.09 gr.) will produce decided but 
not serious symptoms, and that from one to three centigrammes (0.154 
to 0.462 gr.) are poisonous, and from five to ten centigrammes (0.77 
to 1.54 gr.) fatal. Tardieu places the minimum lethal dose at from 
ten to fifteen centigrammes (1.54 to 2.31 gr.). The escapes from death 
after the ingestion of large amounts of arsenic have, without doubt, 
depended upon its being, as in the cases above narrated, in an insoluble 
form. The effects of the arsenical solutions, such as Fowler’s, are more 
rapid and severe than those of the solid drug. 

As arsenic in large doses generally induces vomiting, it is very rarely 
necessary in poisoning to evacuate the stomach by artificial means. If 
free emesis, however, have not occurred, a prompt emetic, such as mus¬ 
tard or sulphate of zinc, should be at once exhibited, and very gener¬ 
ally the stomach should be well washed out by large draughts of warm 


512 


GENERAL REMEDIES. 


water, with salt, if necessary for the return of the water. With the 
emetic, or sooner, if possible, the antidote should be administered. The 
substance whose antidotal value has been most thoroughly tested and 
assured by clinical experience is the freshly precipitated, sesquioxide of 
iron , which forms with arsenious acid a very insoluble compound. The 
antidote must be freshly prepared, and must be given in great excess: 
accoi’ding to the experiments of Messrs. T. and H. Smith, of Edinburgh, 
at least eight grains of the iron being required for the conversion of one 
grain of the arsenious acid. In practice, any of the sesqui solutions of 
iron—that of the chloride being generally preferred, as most readily 
procured—should be neutralized by carbonate of sodium or preferably 
by magnesia, and a portion of the precipitate given at once, stirred 
up in hot water. The remainder of the antidote, having been hastily 
washed by emptying it on to a piece of muslin or a filter, pouring 
water on it and allowing it to drain, should be administered very 
freely,—indeed, indefinitely, as it is entirely harmless. H. Kohler, of 
Halle (Brit, and For. Med.-Chir. Rev., 1870, vol. xlv. p. 538), has made 
a very elaborate series of chemical, physiological, and clinical experi¬ 
ments upon the comparative antidotal values of the saccharated oxide 
of iron and the freshly-precipitated sesquioxide. His results indicate 
that the former preparation is the better; but, as the efficiency of the 
sesquioxide has been so frequently proved at the bedside, further testi¬ 
mony is desirable before it is superseded, especially since the other ferric 
preparation is not officinal with us, and is not so readily prepared on the 
spur of the moment as its fellow. Dialyzed iron has been used with 
very good results, but it is much better to precipitate it, just before 
administration, with a small amount of ammonia or other alkali. Mag¬ 
nesia, fx-eshly calcined or freshly precipitated from a solution of its salts, 
is an antidote of some avail in arsenical poisoning, but is decidedly less 
efficient than the oxide of iron. 

Under the name of Ferri Oxidum Hydratum cum Magnesia, the ar¬ 
senical antidote of the German Pharmacopoeia was recognized at the 
1880 revision of the U. S. Pharmacopoeia. It is made by precipitating 
the solution of the tersulphate of iron by magnesia, and is probably 
the best of the antidotes. In emergencies, Monsel’s solution, tincture 
of the chloride of iron, or other of the sesqui preparations of iron, may 
be substituted for the tersulphate. 

After the emetic has acted in a case of arsenical poisoning, and 
while the antidote is being given, castor oil should be administered, 
for the purpose of expelling the poison from the bowels. The further 
treatment should be directed by general principles,—demulcent drinks, 
opium, stimulants, dry external heat, and rubbing, being employed as 
called for by the symptoms. When there is a tendency to suppression 
of urine, very large draughts of water containing sweet spirit of nitre 
should be given as frequently as the stomach will bear them. 

The chief indications in chronic arsenical poisoning are to remove the 


ALTERATIVES. 


513 


patient from the exposure and to treat symptoms as they arise. Al¬ 
though I do not know of any clinical records bearing upon the subject, 
it might be well to exhibit the iodide of potassium, in the hope of 
hastening the elimination of the poison. 

Administration.— The commencing dose of arsenic is one-twentieth 
of a grain, which should be given in pill after meals, and be slowly 
increased until a perceptible influence, or the desired therapeutic effect, 
is obtained. In many cases (chorea, lymphoma, intermittent fevers, 
etc.) it is necessary to push the remedy until decided evidences of 
poisoning are secured: in this case a liquid preparation should be 
selected. The following are the officinal preparations of arsenic: 

Liquor Potassii Arsenitis—Solution of Arsenite of Potassium. — Fowler's 
Solution contains four grains of arsenious acid to the ounce, is nearly 
colorless, odorless, with a very faint taste of the compound spirit of 
lavender, which is in it. It is an excellent preparation. The average 
commencing dose is five drops in a wineglassful of water after meals, 
to be increased and used with the same precautions as arsenic. 

Sodii Arsenias—Arseniate of Sodium. —This salt occurs in transparent, 
slightly efflorescent, soluble crystals, and is solely used in making the 
Liquor Sodii Arseniatis. The Solution of Arseniate of Sodium (gr. 4.6 
to f3i) may be used instead of Fowler’s Solution, in similar doses. 

Arsenii Iodidum—Iodide of Arsenic. —This is an orange-red, crystal¬ 
line solid, wholly soluble in water and entirely volatilized by heat. It 
has been used as an alterative, and also as an external application in 
certain diseases of the skin, especially lupus and chronic tubercular affec¬ 
tions. Iodide of arsenic enters into Donovan's Solution. 

Liquor Acidi Arseniosi—Solution of Arsenious Acid, is of the same 
strength, and has the same therapeutic properties, as Fowler’s Solution. 
It is, however, a little more irritant than that preparation. 

HYDRARGYRUM—MERCURY. U.S. 

Physiological Action.— When a mild, unirritating preparation of 
mercury is introduced into the system so as to produce constitutional 
effects, the first symptoms of its action are to be looked for in the 
mouth. In the mildest degree these symptoms consist of a slight fetor 
of the breath, and some soreness of the teeth when knocked forcibly 
together or struck with a key. Mercurial fetor is peculiar, and is gen¬ 
erally the first indication that the drug is affecting the system, and is 
sooner or later accompanied by a disagreeable metallic taste. If the 
use of the mercury be persisted in, the gums become swollen, soft, and 
spongy, bleeding on very slight abrasion, and there is a decided increase 
in the seci’etion of saliva. Beyond this point the therapeutist is never 
justified in carrying the use of the drug. If it be done, the local symp¬ 
toms in the mouth increase in severity, the tumefied gums become in¬ 
flamed, very vascular, and marked by a dark-red line at the junction 
of the teeth; the tongue is also swollen, sometimes enormously, pro- 

33 


514 


GENERAL REMEDIES. 


trading from the mouth, whose closure it may entirely prevent; the 
teeth are loosened in their sockets; the saliva is enormously increased 
in quantity and altered in quality, forming great, ropy, viscid masses, 
which pour over the thickened lips; the parotid glands, and even the 
submaxiilary, are very much enlarged, and tender. Sometimes, before 
salivation occurs, slight systemic erethism, marked by a quickened 
pulse and general restlessness, may be present; but when the mouth- 
symptoms are severe, very generally there is a distinct febrile reaction 
of a low type. 

In some cases of mercurialization the stomatitis has been very in¬ 
tense, loss of the teeth, extensive ulceration of the soft parts, and even 
necrosis of the jaw-bones, have occurred, and death from exhaustion 
resulted, or the patient struggled through to recovery, seamed and dis¬ 
figured for life. In these cases passive hemorrhages often recur again 
and again, and, it may be, contribute largely to a fatal result. During 
severe ptyalism emaciation goes on rapidly, and seems to affect es¬ 
pecially imperfectly organized tissues, so that exudations very gener¬ 
ally rapidly disappear. The disturbance of nutrition is further shown 
in some cases by the occurrence of ulcers upon the extremities. The 
blood suffers very decidedly, becoming more fluid and watery than 
normal, and having its power of coagulation impaired. According to 
the researches of Dr. Wright, its solid constituents are notably dimin¬ 
ished, including albumen, fibrin, and the red corpuscles, and it contains 
a large quantity of a fetid, fatty material. These observations of 
Wright have been confirmed upon animals by Dr. Wilbouchewitch 
{Arch. de Physiol ., Sept. 1874), and by Dr. I. Hughes Bennett. 

Although large doses of mercury lower the general nutrition and 
destroy the crasis of the blood, it is by no means certain that given in 
very minute doses it has not tonic properties. In 1869 ( Gaz. des Hop.') 
Liegeois asserted that the subcutaneous injection of very minute doses 
of quicksilver produces in healthy men an increase of their bodily 
weight, and in 1876, in two experiments, Dr. E. L. Keyes ( Amer. Journ. 
Med. Sci., Jan. 1876) found that not only was the bodily weight in¬ 
creased, but, as determined by actual count, the number of the red 
corpuscles was decidedly augmented. Very recently {Arch. f. Exper. 
Path. u. Pharrn ., xiii. 317) Dr. Hermann Schlesinger has laboriously 
experimented upon rabbits and dogs. All other conditions being similar, 
those rabbits which received the mercury increased in weight a very 
lit'.le more than did those to which mercury was not given, but the 
augmentation of the red blood-disks was distinctly greater in the mer¬ 
curialized animals. With dogs the results were more decided, both 
bodily weight and blood-corpuscles increasing much faster in the ani¬ 
mals to which mercury was given. Professor I. Hughes Bennett had 
previously obtained results similar to those quoted, and Dr. Schlesinger 
thinks that it must be considered proved that very minute continuous 
doses of mercurials tend in the normal animal or man to increase dis- 


ALTERATIVES. 


515 


tinctly the weight of the body and the richness of the blood, but that 
it is scarcely proper to call them tonic, as in his belief they act by 
hindering oxidation and restricting waste, and not by aiding in recon¬ 
struction. In this, however, he seems resting upon theory rather than 
upon pi’oved fact, and there is much clinical reason for believing that 
in exceedingly minute doses mercurials in some way benefit nutrition. 
In some cases of syphilitic amemia the effect of mercury in increasing 
the number of red blood-corpuscles is very marked. This effect is, 
however, to be attributed to the antisyphilitic influence of the remedy 
rather than to any specific action on the blood-making organs. (For 
elaborate paper, see Dr. L. Gaillard, Arcli. Gen. de Med ., Nov. 1885.) 

Sometimes the influence of mercury falls almost exclusively upon 
the nervous system, and produces a peculiar train of paralytic phe¬ 
nomena. This occurs chiefly, if not exclusively, when it, as vapor, finds 
entrance to the blood through the lungs, and is most frequently seen in 
those who work in the metah It is generally the result of long ex¬ 
posure ; but that it may be produced in a very short time is proved by 
the case, related by Dr. Christison, of two barometer-makers who slept 
one night in a room containing a pot of mercury upon a stove. One 
was severely salivated, the other was affected with a shaking palsy 
which lasted all his life. According to Dr. Sigmond ( Mercury , Blue 
Pill, and Calomel, London, 1840), the attack of mercurial palsy, which 
is sometimes sudden, sometimes gradual, begins with unsteadiness and 
shaking of the extremities, and of the muscles of the face, which move¬ 
ments interfere with walking, speaking, or chewing; the tremors be¬ 
come frequent, nay, almost constant; “ every action is performed by 
starts.” If the exposure be continued, sleejflessness, loss of memory, 
and death terminate the scene. A peculiar brownish hue of the whole 
body, and dry skin, generally accompany the disease. In its first at¬ 
tack it may be mistaken for St. Vitus’s dance; in its latter stages, for 
delirium tremens. According to Noel Gueneau de JVIussy ( Gaz. des 
Mop., 1868), these two forms are rather distinct varieties than different 
stages of mercurial tremors. In the latter the affection simulates 
paralysis agitans in its shaking movements; in the former the motions 
are violent, and occur independently of the will of the patient, even 
when he is lying quietly in bed. In a case reported by Dr. L. Danger, 
the electro-contractility of the affected muscles was much heightened 
( Wien. Med. Jahrb., 1881, 478). 

Paralysis from chronic mercurial poisoning is said to be not a rare 
affection among artisans and miners who are in their daily occupation 
exposed to contact with the metal or its fumes. The subject has been 
recently thoroughly discussed by Dr. M. M. Letulle ( Archives de Phy¬ 
siol., April, 1887), to whose paper the reader is referred for a collection 
of recorded cases and for details. In a case reported by Dr. Sigmond, 
symptoms similar to those of chronic lead-poisoning, including wrist¬ 
drop, followed repeated mercurial inunctions. In some cases mercurial 


516 


GENERAL REMEDIES. 


paralysis takes the form of multiple palsy, or of a brachial or crural 
monoplegia, or of an obscure local palsy, as in a case reported by Kiiss- 
maul, in which there was aphonia from paralysis of the laryngeal mus¬ 
cles. Almost invariably the loss of motor power is accompanied by 
an anaesthesia, which may be wide-spread or may be in isolated islets, or 
may take the form of hemiamesthesia. The loss of sensation is very 
rarely absolute; simple loss of the thermic sensibility or analgesia may 
exist alone. Partial anosmia or amblyopia may show that the nerves 
of special sensation are affected. Neuralgic pains may be the perma¬ 
nent result of a mercurial exposure, and epilepsy and even insanity, 
most frequently of the melancholic type, are stated to have been so 
produced. According to Letulle, trophic changes are not common, the 
paralyzed muscles not undergoing atrophy, and retaining their normal 
relations to the galvanic and faradic currents. When the thighs are 
affected the knee-jerk may entirely disappear. 

In some cases, exposure to the vapor of mercury, or even its per¬ 
sistent medicinal use, has resulted in the production of a state of the 
system somewhat resembling scurvy, characterized by great anaemia, 
emaciation, and general loss of power, with loss of the hair, aching 
pains in the bones and joints, oedema, fetid breath, diarrhoea, and gener¬ 
ally disordered secretions. This is the so-called mercurial cachexia. 

As already stated, the salivary glands are especially sensitive to the 
constitutional effects of mercury, and there is some reason for believing 
that the pancreas, which resembles them in structure, is also obnoxious 
to the drug. Thus, in a case related by Dr. Copland, a woman after 
excessive salivation experienced deep-seated epigastric pain and heat, 
with nausea, thirst, and fever, and voided thin stools containing liquid 
resembling salivary fluid. At the post-mortem the pancreas was found 
weighing four ounces, red, congested, and with its duct dilated. In re¬ 
gard to the action of mercury upon the liver, see article on Calomel as 
a purgative. 

It is asserted that in some peculiar persons the external, and even 
the internal, use of small amounts of mercurials will produce violent 
eczema or other skin-eruption (Dr. Alexander, Vierteljahrs. f. Dermatol, 
u. Syph., xi. 110). 

Little attention has been paid to local mercurial poisoning, but Dr. 
A. W. Foot has reported ( Dublin Journ. Med. Sci., 1873) the production 
of paralysis of the muscles of the hand and forearm by contact with 
the red iodide of mercury during the rubbing of cattle with a salve 
containing it. 

That mercury is absorbed there is abundant proof.* That it is 


*■ Dr. S. V. Clevenger (Chicago Med. Gaz., Feb. 20, 1880) believes that mercurials are 
absorbed, and act in the form of excessively minute globules of the pure metal. Many of his 
statements are absurdly extravagant; but his observation that when calomel is given to a 
chicken the metallic globules can be abundantly seen in the blood should be confirmed or over¬ 
thrown by direct experiments. See also Chicago Med. Gaz., 18S0, i. 155. 



ALTERATIVES. 


517 


eliminated by the secretions is also very evident. Thus, it has been 
found in the blood,* * in the urine,f in the serum of ulcers,| in the 
saliva,§ in the faeces,|| in the pus from ulcers, in the seminal fluid,in 
the milk of nursing women,**—indeed, in every conceivable secretion 
and in every tissue. Heller, of Vienna, ff has found it in the aborted 
foetuses of salivated women, and Mayenqon and Bergeret in the urine 
of a baby whose nurse was taking calomel; and both of these observa¬ 
tions have been confirmed by Wei lander. 

It is a matter of much interest to know how rapidly mercury is 
eliminated, and whether, when given internally, it accumulates in the 
system. The recent researches of Mayengon and Bergeret (loc. cit .) 
throw some light upon this point, as well as upon the rapidity of ab¬ 
sorption. They found that if one centigramme of corrosive sublimate 
was given hypodermically to a dog, the urine for the next twenty-four 
hours contained mercury, afterwards none. When a centigramme was 
given daily for ten or twelve days, the urine contained mercury for 
four or five days after the cessation of medication. In their last series 
of experiments, rabbits received the drug, and were killed at different 
intervals: in half an hour the metal could be found in all the tissues, 
the liver and kidneys containing most of it; in four days, or even in a 
shorter time, mercury given in a single dose was all eliminated, and 
could not be found in the tissues. This would seem to prove that mer¬ 
cury given in a single dose does not remain in the system; but the 
experiments of Mayengon and his colleague, confirmed by clinical ex¬ 
perience, show that when the drug is administered repeatedly elimina¬ 
tion ceases before it is all discharged. Thus, forty-eight hours after the 
cessation of a mercurial course, when the urine of one of the investi¬ 
gators was free from the metal, the iodide of potassium was exhibited; 
and the urine of the next twenty-four hours contained an abundance 
of mercury, which continued to be present in diminishing quantities 
for seventy-two hours. The chief channel of escape seems to be the 
kidneys; but it is very certain that, at least in some cases, the drug is 
freely excreted by the salivary glands as well as by the intestines. Dr. 
Schuster has found it in the faeces three months after the cessation of 
a mercurial course ( Viertelj.f . Derinat. u. Syphilis, ix. 307); indeed, he 


As N. Popow found that mercury is capable of producing the same changes in the spinal 
cord as is arsenic (see p. 499), it is probable that in some cases of mercurial poisoning the 
symptoms simulate those of poliomyelitis. 

* Eld and Buchner, quoted by Professor Still6. 

f Cantu, Jourda, Andouard, quoted by Professor Still6. 

J Foureroy, quoted by Professor Still*;. 

$ Gmelin, Bull, de ThSrap., xiii.; Byanon, quoted by Mayenpon and Bergeret; Salkow- 
sky, Virchow’s Arckiv, xxxvii. 347; Oesterlen, quoted by Professor Stille. 

|| Salkowsky, loc. cit., p. 347. 

Maycnfon and Bergeret, Robin’s Journal de VAnatomie, 1873. 

*“* Klinik, Detroit Med. Journ., May, 1877. 

-f-f Quoted by Professor StillS. 



518 


GENERAL REMEDIES. 


believes that it is thrown off more freely and constantly by the intes¬ 
tines than by the kidneys. He also claims that elimination is com¬ 
pleted six months after the cessation of an ordinary mercurial course 
(Journ. of Cutan. Med., i. No. 12, ii. No. 9).* 

The rate of absorption is of course affected by the method of ad¬ 
ministration. Wellander (Ann. Dermatolog., vii. 413) has found mer¬ 
cury in the urine fourteen hours after its application to the skin, and 
one hour after its subcutaneous administration. 

In regard to the constitutional action of mercury we know but 
little, except that in some way it influences nutrition.f It certainly 
increases the secretions, probably by a direct action upon the cells of 
all the glands. It has been shown by Salkowsky that mercury will 
cause in the dog fatty degeneration of the renal epithelium, and in the 
rabbit diabetes, as well as a deposit of the phosphate of calcium in the 
kidneys, which Professor Prevost has shown to be accompanied by a 
decalcification of the bones (Revue Med. Suisse Born., 1882, 553, 605; 
also 1883, 402). These facts, and the emaciation, the perverted func¬ 
tions of nerves and glandular tissue, the various skin-eruptions, the 
altered blood of chronic hydrargyria, all point to a profound impres¬ 
sion on the nutrition of every part of the organism. 

That mercury causes no especial waste or destruction of the nitro¬ 
genous compounds of the body appears to be shown by the researches 
of Dr. Hermann von Boeck ( Schmidt's Jahrbucher, Bd. cxlv. p. 142). 
This observer analyzed the faeces and urine of a man before, during, 
and after the exhibition of mercury, taking proper precautions to as¬ 
sure uniformity as to diet and exercise. There was a slight but not a 
notable increase in the amount of nitrogen in the two excretions during 
the mercurial period. 

Therapeutics. —The use of mercury in affections of the liver and 
of the alimentary canal is fully discussed in another portion of this 
work; and, although the drug has been used for almost innumerable 
purposes in times past, it seems here only necessary to speak of its 
action as an antiphlogistic Mid as an antisyphilitic. 

Antiphlogistic action .—The use of mercury in inflammation origi- 


* These papers of Schuster’s have given rise to some controversy, and a valuable discus¬ 
sion as to the best methods of finding mercury in the excreta. See papers quoted above; also 
Viertelj. f. Dermat. u. Syphilis, 1882, No. 702; Annales de Dermcit. et Syph.il., iii. 1882, 
721. Sigismund has found quicksilver in the urine of patients as long as thirteen years after 
taking the medicine; but Schuster ( Zeitschr. f. Klin. Med., vii. 1884) asserts that these 
patients were habitues of a room in which inunctions were constantly being made, and that 
under these circumstances there is sufficient diffusion of the mercury to produce a very 
sensible effect in those breathing the air. 

j- For an article by A. Polotebenow, of St. Petersburg, on the effect of mixing corrosive 
sublimate albuminate with blood outside of the body, see Virchow’s Archiv, 1864, Bd. xxi. 
p. 35. Mercury acts upon the lower mammals as it does upon man, but experimental research 
has as yet thrown little light upon the method of its action. For the latest research and 
literature of the subject, see Arch./. Exper. Path. u. Pharm., xiii. 86. 



ALTERATIVES. 


519 


nated towards the close of the last century with a Dr. Robert Ham¬ 
ilton, and soon became universal in England and America. It is a 
matter of regret that no sufficient analysis of the blood of ptyalized 
persons has been made to determine exactly what are the changes pro¬ 
duced in the vital fluid by mercury. The indications are, however, very 
strong that chief among them is a lessening of the amount of fibrin. 
As is well known, increase of the hsemic fibrin is one of the most char¬ 
acteristic effects of inflammation: consequently, theory, instead of 
being opposed to the antiphlogistic use of calomel, affords at least 
some grounds for the belief that there is more or less of antagonism 
between the processes of mercurialization and of inflammation. 

All important evidence as to the antiphlogistic value of mercurials 
at present available is clinical, and even of this it seems impossible to 
find much that is very exact and of such nature as to exclude possible 
fallacies. It is the enormous mass of testimony that overrides the 
chance of fallacies. It is the general judgment of the profession, 
founded upon the thousand daily-observed bedside facts, that endorses 
the use of mercury as an antiphlogistic. In other words, our knowl¬ 
edge of the value of mercurials in inflammation at present is clinical 
rather than experimental, empirical rather than scientific, but it seems 
scarcely possible that it is not correct. There is one inflammatory affec¬ 
tion, iritis , which, from its anatomical relations, is completely visible 
at all stages; and the effects of the drug upon its processes have been 
noted from day to day hundreds of times. Oculists are, I believe, 
agreed that when there is a marked tendency towards the exudation 
of lymph in this disease, mercury should be exhibited until ptyalism is 
induced. 

Of all inflammations, those of the serous membranes seem to be most 
allied to iritis; and it is exactly in the condition above spoken of, where 
there is a tendency to fibrinous exudations in pleuritis , peritonitis , and 
pericarditis , that mercury is so constantly employed with so good an 
effect. In parenchymatous inflammations, especially in pneumonia and 
in hepatitis , mercury has been used with asserted advantage by many 
practitioners, but its value is certainly more questionable than in serous 
inflammations. Calomel is useful in severe laryngitis, and especially 
in the pseudo-membranous variety, when the type is sthenic; and no 
time should be lost in bringing the system under its influence. The 
extent of its power to arrest the course of endocarditis is certainly an 
open question ; but, as it is extremely important, if possible, in this 
disease, to prevent exudation, and as mercury is the most efficient 
known agent for effecting this, it should be administered freely and at 
once. If the disease be of rheumatic origin, the alkalies may be ad¬ 
ministered conjointly with the mercurial. 

In whatever disease a mercurial is administered as an antiphlogis¬ 
tic, it should be given during the stage of exudation, and to facilitate 
the absorption of the newly-organized lymph after it has ceased to be 


520 


GENERAL REMEDIES. 


thrown out. In the majority of cases, mercury given for its constitu¬ 
tional effects should be combined with opium, to prevent its acting on 
the bowels. 

Calomel should not be used in adynamic inflammations , or where the 
exudation is serous rather than fibrinous. In puerperal peritonitis it has 
been strongly advocated by some, and as strongly condemned by others, 
simply because there are two varieties of the disease, the sporadic or 
sthenic , and the epidemic or asthenic ; and in the one both bleeding and 
calomel are strongly indicated, while in the other they are effective 
only for evil. 

Mercury as an Antisyphilitic. —It was formerly believed that syphilis 
could not be cured without the use of mercury; but latterly there has 
arisen a school of syphilographers who assert that the drug is not only 
not necessary, but is at all stages and in all cases of the disease most 
injurious; that the worst symptoms of the disease are due not to the 
constitutional affection, but to the remedy given for its relief. The 
great bulk of the profession occupies a middle ground between these 
extremes, holding the opinion that while mercury is not absolutely 
essential for the relief of syphilis, it is yet in many cases of the utmost 
value when judiciously used. The justice of this position cannot, I 
think, be rightly questioned; the universal verdict in its favor is too 
fixed and definite: so that the important point now is to determine at 
what stages, and under what conditions, the remedy is advisable, and 
w r hat is the best method of its application. 

Syphilis is ordinarily, and with sufficient accuracy for practical 
purposes, divided into three stages, the primary, the secondary, and 
the tertiary. According to the teachings of the dualists, there are two 
varieties, or rather species, of venereal ulcer, the hard and the soft 
chancre, or the true chancre and the chancroid, the infecting and the 
non-infecting sore. When a venereal ulcer offers the characteristic of 
the latter of these, mercury should never be exhibited. So long as 
there is a doubt as to the nature of the primary sore, the remedy 
should be withheld; but when there is distinct induration, and the 
inguinal glands begin to be involved, it should be given. 

It is proper to state that some high authorities deny the expediency 
of giving the mercurial until the appearance of distinct secondaries. 
They affirm that mercury is powerless to prevent the occurrence of 
these phenomena; that the good which it does is found in its hastening 
their completion, and consequently that it should be reserved until the 
second stage of the disorder. I myself believe this is incorrect prac¬ 
tice, and that minute doses of mercury should be given continuously 
for many months so soon as undoubted syphilitic symptoms are mani¬ 
fested. The careful experiments of Iveyes (Amer. Journ. Med. Sci., Jan. 
1876) have shown that under these circumstances such small doses 
act as a tonic, increasing the number of the red blood-disks. Ptyalism 
is to be avoided unless the symptoms urgently demand it. 


ALTERATIVES. 


521 


In tertiary syphilis mercury is to be used cautiously. It is not, 
however, the mere length of time that has elapsed since the infection, 
but the condition of the patient, that guides the judicious practitioner. 
So long as there is no decided cachexia, if the patient has not recently 
been through a mercurial course, mercury should be freely used when 
the local lesion threatens life. Thus, a gumma in the heart-wall, in the 
upper spinal cord, or in some vital brain-region may imperatively de¬ 
mand active mercurialization. I have twice seen a patient slowly re¬ 
covering from brain-syphilis under the influence of the iodides die by the 
accident of an epileptic arrest of respiration. In these cases the more 
rapid resolution of the gummatous masses by mercury, had that drug 
been exhibited, would in all pi’obability have prevented the fatal fit. In 
hereditary syphilis a prompt mercurial impression offers the best chance 
of relief. Even in the primary or secondary stages of syphilis mercury 
should be employed with caution and judgment. In his researches (loc. 
cit.) Wilbouchewitch found that the mercurial when first exhibited 
increased the number of red blood-coi'puscles in syphilitic patients, but 
after a time appeared to produce anaemia. Whatever preparation be 
employed, it should be so administered as to exhibit only signs of its 
constitutional action upon the mouth. It is not necessary to ptyalize 
the patient severely, or indeed at all, the proper course consisting in 
the steady maintenance of the slightest possible distinct soreness of 
the gums. There are various methods by which this may be done. 
That most frequently employed, because most convenient, is the admin¬ 
istration of small doses of calomel or blue pill by the mouth: from 
one-fourth to one-half grain of calomel, or twice as much of the blue 
mass, combined, if necessary, with opium, to prevent its action upon 
the bowels, may be given three times a day, and increased if required. 
Instead of the internal use of the mercurial, the system may be brought 
under its influence by inunctions with unguentum hydrargyri. When 
this is done, the skia should be well cleansed and softened by frequent 
bathing, and then a drachm of the ointment may be rubbed into the 
inside of the thighs, legs, and the popliteal spaces, in such a way that 
the application be not made to any spot oftener than every other day. 

It is commonly advised in English works to employ the armpits; 
and, as the skin is there exceedingly thin and the absorbents very 
numerous, mercury is without doubt more rapidly taken up at that 
place than at any other part of the bodj r . When, however, mercury is 
applied to any hairy surface, it very commonly in a short time induces 
a troublesome eruption, due to inflammation about the hair-follicles. 
The eruption appears anywhere on the skin if the mercurial ointment 
be applied too freely; and, in order to avoid this inconvenience, in 
Germany the following plan is adopted (Dr. II. Zeissl, Lehrbuch der 
Syphilis , Theil ii. p. 349): the patient, having been prepared by thor¬ 
ough warm bathing, and having received about half a drachm of the 
ointment, is directed to place it in the hollow of the hand and to rub 


522 


GENERAL REMEDIES. 


the two hands together until the ointment is equally diffused, then to 
apply it forcibly and slowly to the part directed until almost all of the 
salve has disappeared, having been rubbed into the skin. In most cases 
the mercurial is applied daily, but in very susceptible persons only 
every third day. A regular order is maintained in the application, as 
follows: first day, inner side of both upper arms; second day , inner 
side of both thighs; third day , inner side of both forearms; fourth day , 
inner side of both legs; fifth day , upon both groins; sixth day, upon 
the back; seventh day, recommence the series. 

The advantage claimed for inunction is that the digestion is less apt 
to be disturbed than when the drug is exhibited by the mouth; the dis¬ 
advantages are the greater or less publicity which it entails, the trouble 
which it involves, and its apparent dirtiness. In private practice it is 
rarely used except in the case of infants, when the mercurial ointment 
is rubbed into the abdomen and armpits, or often simply smeared upon 
the flannel roller or binder which usually envelops the body. The 
mercurialization of the nurse, with the object of affecting the child, 
is unjustifiable, unless the nurse and the nursling are alike diseased: 
indeed, to allow a syphilitic child to feed at the breast of a healthy 
woman is a crime. 

Mercury is sometimes administered in secondary syphilis in the foi’m 
of fumigations. The patient is placed upon a chair, and surrounded by 
a large blanket, or, better, india-rubber cloth, so arranged as to fit 
tightly around his neck above, and below to encompass the chair. The 
mercurial preparation is placed upon a metal plate, heated by a spirit- 
lamp, beneath the chair, and the fumes are allowed to fill the space 
around the patient inside of the blanket. The heat produced generally 
causes the patient to sweat profusely, and in from fifteen minutes to 
half an hour the lamp should be withdrawn, and the patient allowed to 
cool off, and after a time be put to bed and wrapped up in blankets, 
with the deposit of mercury still adhering to the skin. The fumigation 
may be practised every other night, or at longer intervals, and is be¬ 
lieved by some to be especially useful in cases of secondary skin-erup¬ 
tions. Calomel, black oxide, and cinnabar are the preparations generally 
used. When the last is employed, care must be exercised that the 
patient do not breathe the fumes. 

In advanced secondary and tertiary syphilis, the iodides of mercury, 
given by the mouth, are often very useful, but the combination of the 
corrosive sublimate and the iodide is in many cases still more efficient. 
Usually not more than one-twelfth of a grain of the bichloride should 
be given, three times a day.* 


* The hypodermic use of mercury does not seem to me justifiable. As to the relations of 
sublimate to albumen and albuminous compounds for hypodermic use, consult Arch.f. Exp. 
Path. u. Pharm., iii., 1875; Wiener Med. Woch., xxvi. 11, 1876. M. M. Martineau claims 
that ammoniacal mercurial peptones may be used hypodermically in syphilis with great ad¬ 
vantage. The formula may be found in Lond. Med. Record, 1882, p. 47. 



ALTERATIVES. 


523 


Administration. —The following preparations contain metallic mer¬ 
cury : 

Unguentum Hydrargyria TJ.S.— Blue, or Mercurial, Ointment is made 
by triturating mercury with suet and lard until the metal is extin¬ 
guished,— i.e., until a portion of the mass rubbed upon a piece of paper 
exhibits no globules under a magnifying power of four diameters. 
Mercurial ointment is soft, of a bluish color, becoming darker by age, 
and contains half its weight of mercury. When frequently rubbed 
upon the same part, it not rarely produces a disagreeable eruption. It 
is used to make a constitutional impression, and also locally as a re¬ 
solvent, in cases of enlarged indurated glands. The oleate of mercury 
(.Hydrargyri Oleatum —1 to 10, TJ.S.) appears to be a more elegant 
preparation than blue ointment, and equally efficient. 

Emplastrum Hydrargyri, TJ.S.— Mercurial Plaster contains mercury, 
olive oil, resin, and lead plaster, and is used as a resolvent in indurated 
glands , enlarged chronically inflamed joints, etc. 

Massa Hydrargyri, TJ.S.— Pills of Mercury—Blue Mass is made by 
extinguishing mercury with honey and other inert substances. It con¬ 
tains one-third its weight of the metal, and is used for the same purpose 
as calomel, but is milder. Dose: purgative, grains 5 to 10; alterative, 
grains 1 to 3. “ Blue Pills ” usually contain each three or five grains of 

the mass. 

Hydrargyrum cum Creta, TJ.S.— Mercury with Chalk—Gray Powder 
is made Avith chalk. It is a smooth, grayish powder, and is similar in 
its medical properties and strength to blue mass. 

HYDRARGYRI CHLORIDUM MITE—MILD CHLORIDE OF MER¬ 
CURY. U.S. 

Calomel is made by boiling- mercury and sulphuric acid together in 
such proportions as to form a bisulphate of the deutoxide of mercury, 
reducing this to the simple sulphate of the protoxide of mercury by 
triturating it with more of the metal and subliming with the chloride 
of sodium. The sublimate is to be well washed with water, to remove 
any of the bichloride that shall have been formed owing to the imper¬ 
fect reduction of the bisulphate to the sulphate. When the Avashings 
are no longer affected by the addition of ammonia, it may be known 
that the drug is free from the soluble corrosive sublimate. Calomel is 
sometimes manufactured by precipitating corrosive sublimate by sul¬ 
phurous acid ; but this method is not officinal, and is subject to serious 
disadvantages. 

Physiological Action.— Chving to the great insolubility of calomel, 
a good deal of discussion has occurred as to the Avay by Avhich it finds 
entrance into the system. The theory of Mialhe ( Chimie appliquee), a 
modification of one originally advanced by Snow (Lancet, 1840), has 
been pretty Avidely accepted, though with some hesitation, but is, I 
think, untrue. According to the chemist named, the calomel is con- 


524 


GENERAL REMEDIES. 


verted by the chlorides of the stomach into corrosive sublimate, and as 
such is absorbed. The action of calomel upon man is so different from 
that of corrosive sublimate as to render this theory exceedingly im¬ 
probable, and, at temperatures even higher than that of the stomach, 
Mialhe was never able to obtain the formation of more than a sixteenth 
of a grain of the sublimate by the gastric juices. Further, Bucheim, 
Oettingen, and Winkler (quoted by Professor Stille, Therapeutics , 2d ed., 
p. 655) affirm that this conversion does not occur at all at the tempera¬ 
ture of the body. Jeannel (Schmidt’s Jahrbucher, Bd. cxliii. p. 9 ; from 
Journ. de Bordeaux , 4e ser., t. ii. p. 67, 1869) has confirmed this, and 
has suggested what seems to be the way in which calomel is absorbed. 
He finds that when the protochloride of mercury is placed in a solution 
of an alkaline carbonate it is decomposed and the gray oxide precipi¬ 
tated. A small portion, however, of the latter is held in solution, as 
much as 0.02 part in 50 parts of water (by weight); and if a fatty oil 
bo mixed with the alkaline solution a very large part of the mercury is 
dissolved. From these facts it would seem to follow that the calomel 
entering the stomach escapes unchanged into the alimentary canal, and 
is there decomposed by the alkaline juices and dissolved by the fatty 
matters usually present. The physiological evidence appears to con¬ 
firm this, for calomel, being absorbed in this way, ought to resemble 
blue mass rather than corrosive sublimate in its action,—which it does. 

The varying constitution of the alimentary juices and the complex 
chemical relations of calomel would indicate that its solution in the 
alimentary canal is accomplished in more ways than one,—an indica¬ 
tion which is confirmed by the varying results following the ingestion 
of the drug. It is probable that at times, when the stomach contains 
more than usual of chlorides and of hydrochloric acid, a very slight 
portion of the calomel is converted into corrosive sublimate, and that 
when there is an excess of sulphuretted hydrogen in the alimentary 
canal a soluble sulphide may be formed. 

Since the labors of Hunter and Hebra, syphilographers have been 
experimenting with the hypodermic use of mercury. That it is possi¬ 
ble to produce the mercurial impression very rapidly and very success¬ 
fully in syphilis by such method is proved beyond cavil. The practical 
difficulty has been the production of local abscesses. It is said that by 
Smirnoff’s modification of the plan of Scai’enzio this obstacle has been 
largely overcome. The preparation used is calomel mixed with water 
and chloride of sodium in such manner that the mixture contains ten 
per cent, of each ingredient. It is essential that the hypodermic in¬ 
jection be made in the buttocks, in the neighborhood of the vertical 
fold or depression which occurs in most lean persons about one inch and 
a half behind the great trochanter. According to Smirnoff, the advan¬ 
tages of this treatment are its simplicity and ease, its efficiency, and 
the little liability to produce serious mercurialization. One and a half 
grains of calomel may be used in each injection, the two injections being 


ALTERATIVES. 


525 


administered at once on opposite sides of the body. The injection should 
not be repeated in less than four days, and may be employed only once 
a week. I tried the plan in one case, with the result of a sloughing 
ulcer two inches deep. Various other preparations of mercury have 
been used instead of calomel; especially is the yellow oxide suspended 
in liquid vaseline commended by Balzer and other French physicians. 
It appears, however, to produce more irritation than does calomel* Bel¬ 
lini states that severe constitutional symptoms are liable to be produced 
in persons who are taking alkaline iodides or bromides. 

The influence of calomel upon the system has been sufficiently dis¬ 
cussed. It remains only to state that its freedom from all irritant 
properties is shown when taken internally or when used externally. 
Probably no single dose of it is capable, in the average man, of acting 
as a violent poison, since it is stated that in the Western United States 
it is very frequently taken in teaspoonful doses, that sixteen grains of 
it will act as vigorously as an ounce, and that a pound of it has been 
given in a case of cholera without visible effect.f It seems to me most 
probable that the absence of serious results from these heroic amounts 
is due to the alimentary canal being unable to dissolve— i.e., to absorb 
—the calomel. F. D. Lente has claimed that given in this way the 
drug acts as a sedative and does not produce mercurialization, and Mrs. 
Putnam-Jacobi believes such doses to be valuable in diseases where 
there is “ sudden over-distention and paralytic congestion of extensive 
regions of small blood-vessels.” (See New York Med. Journ., xi., 1870 ; 
xxix., xxx., 1879.) An abundance of clinical authority could be found 
for the statement that calomel may act as a positive diuretic, and there 
seems little doubt that under some circumstances this influence is dis¬ 
tinctly manifested, especially when there is a tendency to hepatic torpor 
or other abnormal hepatic condition prone to be relieved by mercurials. 
The old combination of digitalis, squill, and calomel is in many cases of 
pleuritic effusion and heart-dropsy superior to the digitalis and squill 
alone, and is especially indicated when there are hepatic symptoms. 

Administration. —When it is desired to produce constitutional mer¬ 
curialization, the dose of calomel is a half to one grain ; as a purgative, 
from six to ten grains are administered, and followed in six hours by 
Seidlitz powder, or other saline, if required; or, as is preferred by some 
practitioners, a quarter of a grain is given every hour until three grains 
are taken or purgation is induced. Minute doses (one-sixth of a grain) 
of calomel given every hour afford a very good method of impressing 
the system rapidly. When it is desired to get its constitutional influence, 
it is generally necessary to conjoin opium with it, to prevent purging. 


* Consult Lo Sperimentale, June, 1873 ; London Medical Record, 1873; Kolliker ,Centralbl. 
fur Chir., 1877, 97; Bull. GSn. de Thirap., cxii. 302; Med. Wochenschr., No. 6, 1887; JV. Y. 
Medical Record, July, 1887. 

■f Professor George B. Wood’s Therapeutics, vol. ii. p. 565. 



526 


GENERAL REMEDIES. 


HYDRARGYRI CHLORIDUM CORROSIYUM—CORROSIVE CHLORIDE 

OF MERCURY. U.S. 

Bichloride of Mercury , or Corrosive Sublimate , is made by subliming 
the bisulphate of mercury with common salt. It occurs in the form 
of colorless crystals, or of white, semi-transparent, crystalline masses, 
of an acrid, metallic, styptic, and very persistent taste, soluble in six¬ 
teen parts of cold and in three of boiling water. It is at once distin¬ 
guished from the other mercurial preparations by its color, taste, and 
solubility, and by its forming a yellow precipitate with lime-water. 

Physiological Action.— Corrosive sublimate is a violent irritant, 
and in concentrated form caustic. When given in small repeated doses, 
although capable of inducing salivation, it is less apt to do so than is 
calomel or blue pill. In overdoses it produces symptoms of irritant 
poisoning of a severity proportionate to the dose. If the latter be 
small, the manifestations may be only some nausea, slight burning in 
the stomach, colicky pains in the abdomen, and diarrhoea. After large 
doses these symptoms are intensified. The subject first experiences a 
peculiar metallic, coppery taste at or shortly after swallowing the 
poison. If the solution be concentrated, deglutition is interfered with 
by a spasm of the muscles of the throat and larynx, causing a feeling 
of suffocation, and sometimes even the rejection of the draught. Then 
burning pains are experienced in the oesophagus and stomach, followed 
by violent vomiting, at first mucous, then bilious, and finally bloody, 
and by severe abdominal pain and tenderness, with profuse purging, at 
first serous in character, but afterwards affording only small, mucous, 
bloody stools, which are often voided with much straining. The breath 
generally becomes fetid and offensive in a very short time. In the 
course of two or three hours, very rarely in less than an hour, collapse 
occurs, with small, frequent, irregular pulse, pinched, anxious face, cold 
extremities, and finally death, preceded, it may be, by fainting, con¬ 
vulsions, and coma. The urine is very much lessened in quantity, is 
sometimes albuminous, or even bloody, and not rarely is suppressed. 
If the patient survives several days, a petechial eruption may appear, 
and salivation sometimes, but not always, occurs. In some cases, after 
the collapse there is an attempt at a febrile reaction, which soon, how¬ 
ever, gives place to a second and fatal prostration. When recovery 
occurs after severe poisoning, the convalescence is slow and protracted. 

In regard to chronic poisoning with corrosive sublimate, sufficient 
has been said under the general heading, except that colicky pains and 
abdominal disturbance are more apt to occur with it than with the less 
irritating preparations. MM. Arnozan claim that chronic catarrh of 
the excretory ducts of the pancreas is a pronounced lesion in chronic 
poisoning of animals (Journal de Bordeaux , Dec. 1883). It should be 
looked for in man, and its presence might be of medico-legal value. 

Severe purging, and even fatal poisoning, may result from a single 


ALTERATIVES. 


527 


external application of this preparation of mercury;* and in animals 
killed by hypodermic injections of it (see experiments of Dr. J. Rosen- 
bach, Schmidt's Jahrbucher , Bd. cxliii. p. 9) diarrhoea and other indica¬ 
tions of gastro-intestinal irritation are prominent symptoms,—facts 
which indicate that the bichloride is eliminated unchanged from the 
alimentary canal. 

Hydrargyri Iodidum Viride—Green Iodide of Mercury. U.S. 
—This Protiodide of Mercury is made by the direct action of iodine 
upon the metal. It is a greenish-yellow, odorless, and tasteless powder, 
insoluble in water, ether, and alcohol. Compared with the biniodide or 
the bichloride, it is a mild preparation, and has been used to produce 
constitutional impression in syphilis, especially when of long standing. 
The iodide of potassium converts it into the biniodide and metallic 
mercury (U.S. Dispensatory), and should, therefore, never be given in 
combination with it. The alterative dose is one-fourth of a grain three 
times a day, increased to a grain if necessary. 

Hydrargyri Iodidum Rubrum—Red Iodide of Mercury.— The 
Biniodide of Mercury is made by precipitating the bichloride of the 
metal with iodide of potassium. It is a scarlet-red powder, insoluble in 
water, but sparingly soluble in alcohol. It is a powerful local irritant, 
producing, when taken in overdoses, symptoms and results very similar 
to those caused by corrosive sublimate. It is used a good deal in tertiary 
syphilis and in syphilitic rheumatism; also to some extent as a local ap¬ 
plication in lupus (see Annuaire de Therap., 1852). It is much more 
active than the protiodide, and should be used as cautiously and in the 
same doses as corrosive sublimate. 

The U.S. Pharmacopoeia also recognizes the following preparations 
of mercury: 

The deutoxide occurs in two forms, the Yellow and the Red Oxide 
(Hydrargyri Oxidum Flavum, Hydrargyri Oxidum Rubrum). Both 
are used upon ulcers , chancres , etc., solely for their local effects, and are 
stimulant and alterative when diluted, mildly escharotic when in powder. 
From Hydrargyri Oxidum Flavum is made the oleate (Oleatum Hydrar¬ 
gyri —1 to 10, U.S.). The Red Precipitate Ointment ( Unguentum Hydrar¬ 
gyri Oxidi Rubri —1 to 10, U.S.), and the Ointment of the Yellow Oxide 
( Unguentum Hydrargyri Oxidi Flavi —1 to 10, U.S.), very generally re¬ 
quire dilution with lard, and are much used in chronic skin-affections , in 
obstinate conjunctivitis , in psorophthalmia, etc. 


* See case reported by Dr. Meeres, Lancet, Sept. 16, 1871, in which a solution (gr. ii to 
f^i) was applied with a camel’s-hair brush to the head of a child nine years old, for the cure 
of tinea tonsurans. The symptoms were diarrhoea, profuse salivation, and great prostration, 
ending in death. AVashing out the vagina with a solution of corrosive sublimate, one part in 
two thousand, has caused severe and even fatal poisoning. See Centralbl. fur Gyndlcol., 1884, 
No. 13, No. 17; also 1887, No. 47. 




528 


GENERAL REMEDIES. 


The Bed Sulphide of Mercury (Hydrargyri Sulphidum Eubrum, 
U.S.), formerly used a good deal in fumigations, is now rarely employed. 
Turpeth Mineral, or Yellow Subsulphate of Mercury (Hydrargyri Subsul¬ 
phas Flavus, U.S.), a lemon-yellow powder, sparingly soluble in water, 
is a basic sesquisulphate of the deutoxide of mercury, prepared by 
throwing the bisulphate into water, which causes it to break up into a 
supersulphate, which remains in solution, and the salt in question, 
which precipitates. Turpeth mineral has been used as a harsh emetic, 
and also as an alterative, but is now rarely employed. In croup, in 
emetic doses it is still very highly^ esteemed by some practitioners, and 
has been inordinately praised by Dr. Fordyce Barker. It is, however, 
a very dangerous remedy, since, if it fail to vomit, it may cause a fatal 
gastro-enteritis, especially in the young child. Two cases of such char¬ 
acter are recorded by Dr. A. McPhedran ( Med. News, xliii. 682). The 
dose as an alterative is from a quarter to half a grain; as an emetic, 
for a child two years old, two grains repeated in fifteen minutes, if it 
has not operated. Forty grains of it ( Guy's Hospital Reports, vol. x., 
3d series) have caused death in the adult; profuse salivation came on 
in six hours. 

White Precipitate, or Ammoniated Mercury (Hydrargyrum Ammoni- 
atum, U.S.), is a white complex powder, made by precipitating the 
bichloride with water of ammonia. It is used in the form of ointment 
(Unguentum Hydrargyri Ammoniati —1 to 10, U.S.) as a local application 
in various skin-affections. 

Black Wash and Yellow Wash , two non-officinal but favorite prepa¬ 
rations, are respectively made by the addition of a drachm of calomel 
to a pint of lime-water, and of half a drachm of corrosive sublimate 
to a pint of lime-water. They depend for their virtues upon the black 
and yellow oxides of mercury, and are used exclusively as local appli¬ 
cations to chancres and other syphilitic ulcers. The yellow wash is much 
the more stimulating of the two. 


IODUM—IODINE. U.S. 

Iodine is a soft, friable, opaque substance, occurring in crystalline 
scales with a semi-metallic lustre and of a bluish-black color. Its odor 
resembles that of chlorine; its taste is hot and acrid. It is somewhat 
volatile at ordinary temperatures, but when heated to 225° F. melts 
and emits the beautiful purple or violet vapor to which it owes its 
name. It is freely soluble in glycerin, alcohol, and ether, but requires 
seven thousand times its weight of water to dissolve it. With starch 
it strikes a deep-blue color, and this test is so delicate that it will indi¬ 
cate the presence of iodine in four hundred and fifty thousand times its 
weight of water. In testing animal liquids, such as urine, for iodine, a 
small quantity of nitric acid should be added to insure its being free in 
the liquid. 

Physiological Action. —Iodine, when applied to any part of the 


ALTERATIVES. 


529 


body, acts as a very powerful irritant, or, if in highly concentrated 
form, as a mild caustic. The tincture stains the skin yellow, and causes, 
if applied with sufficient freedom, smarting, some erythematous inflam¬ 
mation, and finally desquamation. Its repeated application blisters and 
destroys the cuticle. Upon mucous membranes its action is more in¬ 
tense than upon the skin. 

M hen taken internally, a single moderate dose of iodine causes 
merely some gastric uneasiness and a disagreeable metallic taste in the 
mouth ; when larger amounts are ingested, the gastric uneasiness may 
be intensified into violent vomiting, with increased salivary flow, ab¬ 
dominal pains, and even purging. In sufficient quantity it is a poison; 
although very few deaths have been recorded as caused by it. The 
symptoms produced by toxic doses taken into the stomach are burning 
pain in the oesophagus and stomach, vomiting, purging, smallness of 
the pulse, general deadly pallor, lessening or arrest of the urinary se¬ 
cretion, sometimes violent excitement with convulsions, and collapse. 
Twenty grains of iodine are said to have caused death, and two drachms 
and a half have been recovered from. (For cases, see Woodman and 
Tidy, also Munchener Med. Wochenschr., Feb. 1887.) The vomit is yel¬ 
lowish brown or, if starchy matters have been present in the stomach, 
bluish. The injection of iodine into the cavities of the body for thera¬ 
peutic use has several times been followed b}^ cyanosis, thready pulse, 
repeated vomiting of matters containing iodine, excessive thirst, sali¬ 
vation, difficult urination, swelling of the eyelids, laryngeal pain, vari¬ 
ous eruptions upon the skin, high fever, and albuminuria. Sudden 
death may take place after some days from heart-failure. A character¬ 
istic case is that reported by Dr. E. Eose (NothnageVs Arzneimittellehre , 
Berlin, 1870, 252), in which death resulted from a large injection into an 
ovarian cyst. Very soon after it was given, there ensued severe thirst, 
with great dryness of the throat and mouth, and then painless vomit¬ 
ing of watery matters containing iodine. The whole surface became 
very pale, the extremities cyanosed, the radial pulse very frequent, but 
so small that it could not be counted, the urine very scanty, dark brown, 
and rich in iodine. After a time, reaction occurred. For three days the 
vomiting persisted, the pulse was very frequent, full and hard, and the 
cheek put on the glow of high fever, but the temperature did not rise 
above 37.18° C. On the fourth day, exanthematous blotches, not dis¬ 
appearing on pressure, appeared on the skin and in the mouth ; the 
sputa became bloody; and menstruation occurred, two and a half weeks 
too soon. The urine remained scanty, and on the eighth day, when all 
other symptoms save swelling of the parotids had disappeared, still con¬ 
tained iodine, and was albuminous. On the tenth day, in the midst of 
apparent convalescence, the patient died suddenly. 

In the experiments of Jdrg and his pupils, doses of iodine of a 
grain to a grain and a half gave rise to colicky pains, increased appetite, 
watery stools, an increased secretion of urine, malaise,. and some head- 

34 


530 


GENERAL REMEDIES. 


ache. When the dose was augmented to two grains, a diffused sense 
of heat and sexual excitement were superadded. Other observers have 
noted this abnormal sexual excitement, and some have stated that at 
times it precedes atrophy of the mammae or of the testicles. Professor 
Stille affirms that the menstrual flow may become excessive, or that 
during pregnancy abortion may be caused. Yery large quantities of 
iodine are asserted to have been taken without serious results. Julia 
de Fontenelle (quoted by Stille, Therapeutics , ii. 731) tells of a man who 
took two and a half drachms of iodine without experiencing any re¬ 
markable effects; and Magendie relates the case of a child four years 
old who swallowed ten grains without serious consequences.* 

In the experiments of A. Hoyges and Professor Binz (Arch. f. Exper. 
Path. u. Pharm., x. 229, xiii. 114), preparations of iodine, iodide of 
potassium, and iodoform in fatal doses produced in the lower animals 
wide-spread fatty degenerations. 

If full doses of iodine be exhibited continuously for a length of 
time, a train of phenomena result, known as Iodism. In regard to 
these there has been a good deal of difference of opinion and state¬ 
ment, a difference which seems explainable only upon the supposition 
that different individuals are differently affected by the drug. Pilliet 
(Trousseau’s report on his memoir, Bull, de VAcad. Roy., xxv.), who has 
had wide opportunities and has apparently studied the subject very 
closely, makes three forms of iodic intoxication: first, that in ydiich 
the symptoms are those of gastric irritation ; second, that characterized 
by nervous troubles, neuralgia, ringing in the ears, convulsive move¬ 
ments, disturbed intellection, with coryza, ophthalmia, salivation, vom¬ 
iting, diarrhoea, polyuria, and cutaneous eruptions, and in some cases 
atrophy of the mammae in the female and of the testicles in the malejf 
third, iodic cachexia, caused either by iodine or iodide of potassium 
continuously used for many months. It is said to be most easily in¬ 
duced in goitrous persons, and is characterized by rapid emaciation, 
commencing mostly in the face, and severe nervous palpitations of the 
heart, with excessive appetite, which sometimes precedes and sometimes 
follows the loss of flesh. So long as the drug continues to be taken, 
these symptoms continue to progress, and after a time hysteria or hypo¬ 
chondriasis, with insomnia, manifests itself. The goitre, the mammae, 
and the testicles waste away together; but if the medicine be suspended 
and health gradually returns, while the abnormal growth reappears, the 
sexual glands remain wasted. The second form of iodism of Billiet, 
in which the nervous symptoms are prominent, has been spoken of 
by other authorities; and Brodie has especially noted disturbances of 
vision, and paralysis. 


* For an elaborate, careful study of the action of large toxic doses of iodine upon the 
lower animals, see Hoffmann und Schwalbe’s Jahresbericht, 1S79, 199. 

t For a case of wasting of the testicles, see Phila. Med. Times, vol. iv. p. 661. 



ALTERATIVES. 


531 


Iodism as I have seen it after the therapeutic use of the drug has 
chiefly consisted of affections of the skin or of the mucous membranes 
of the nose and mouth. The symptoms are heavy pain over the region 
of the frontal sinus, coryza, sore throat, ptyalism, and an eruption upon 
the skin, which is usually an acne, but may take almost any shape. 
In its serious forms it becomes pustular or bulla-like, and may be ac¬ 
companied with much dermatitis, ulceration, and even very violent 
constitutional disturbances. Iodic accidents are especially apt to be 
severe when there is kidney-disease, as in a case reported by Dr. F. 
Wolf ( Berlin. Klin. Wochenschr., 1886, p. 580), in which forty grains of 
iodide of potassium given in two days appear to have produced death. 
(See also Journ. Cutan. and Verier. Dis., iv.; Munchener Med. Wochenschr ., 
vols. xxxiii. and xxxiv.) 

Most authorities affirm that iodine and iodide of potassium produce 
similar symptoms. Professor See ( London Med. Record , i. 777) indeed 
asserts that iodine exists in the blood only in the form of an alkaline 
iodide, while Dr. H. Kammerer ( Virchow's Archiv , lix. 467; lx. 527) 
and Professor Binz believe that the iodides are decomposed in the 
tissues and act by the liberation of the iodine.* I do not think, how¬ 
ever, that these views can be accepted as completely established, and 
the general professional belief is that the therapeutic value, and con¬ 
sequently the phj'siological action, of iodine and iodide of potassium 
are different. Iodine is universally preferred in scrofulosis, the iodide 
in rheumatism. I have given the salt in enormous doses, and have 
seen nervous symptoms in only a single case,—a man who received for 
a long time two hundred and seventy grains a day, and who was in¬ 
tensely sleepy and stupid, presenting symptoms exactly similar to those 
of bromism, including an eruption of acne. 

Of the physiological action of iodine we know little more than that 
it modifies nutrition. Locally the drug is an irritant, and sometimes 
gastric symptoms are produced by it from this cause. The general 
erethism which it induces is believed by Professor See to be produced 
by a direct excitement of the circulation, and even the nervous symp¬ 
toms are attributed to the same cause,—all of which is very improbable. 
Iodine is certainly absorbed and is eliminated chiefly by the kidneys, 
but probably to a greater or less extent by all the mucous membranes; 
and Dr. R. W. Taylor (. American Journal of Syphilography and Derma¬ 
tology , April, 1873) believes that he obtained in a case evidences of the 


* Consult also Professor Bucheim (Arch. f. Exper. Path. u. Pharrn., Bd. iii.). Dr. Dubu- 
jadoux (Gaz. Hebei., 1883, xx. 24) found that iodine injected into guinea-pigs suffering from 
malignant pustule has no influence upon the disease, even if the injections be repeated until 
they kill the animal, and that the blood also is as poisonous as ever to other guinea-pigs. 
This led him to believe that the iodine exists in the blood in a new compound which is not 
antiseptic. He believes this compound to be albuminous, because he has found that iodine 
mixed with milk or albuminous solutions soon disappears, so that it cannot be recognized 
by the starch test, and that shortly after this disappearance putrefaction sets in. 



532 


GENERAL REMEDIES. 


free escape of the iodine through the skin. Professor See asserts 
(.London Med. Record , i. 757) that the elimination takes place slowly 
and intermittently, so that the drug when given continuously accumu¬ 
lates in the system. He further states that it can be found in the saliva 
after it has disappeared from the urine. The iodine seems to be elimi¬ 
nated partly as an alkaline iodide and partly in organic combination 
(E. Harnack, Berlin. Klin. Wochenschr ., 1882, No. 20). 

During its passage through the kidneys iodine undoubtedly exerts 
an influence upon those organs, as is shown by its producing albumi¬ 
nuria at times. It is indeed asserted that it occasionally causes a true 
tubular nephritis. The evidence as to its effect upon the solids of the 
urine is both contradictory and insufficient. M. Babuteau* dieted him¬ 
self for five days, measured the quantity of urea daily eliminated, took 
iodine on the fifth day, and found a decided decrease in the excretion 
of urea. It is plain that this experimentation was too slight to be of 
much value, and Dr. Hermann von Boeck ( Zeitschrift fur Biologie, iii. 
393, 1869; Schmidt's Jahrbiicher, Bd. cxlv. p. 142) found that the inges¬ 
tion of iodine does not increase notably the elimination by the kidneys 
or bowels. On the other hand, M. Bouchard (quoted by See) declares 
on his personal experience that iodine does increase the daily elimina¬ 
tion of urea, especially in diabetic patients. Dr. C. Handheld Jones 
(. Beale's Archives , i.) anatyzed the urine of six patients taking large 
doses of iodide of potassium, with the following results: first, water 
increased in three cases very much, in one slightly so, in two dimin¬ 
ished ; second, acidity increased in three and diminished in two; third, 
urea increased in three and diminished in three; fourth, phosphoric 
acid and sulphuric acid increased in four and diminished in two; fifth, 
chlorine increased very greatly in two cases, moderately in one, and 
decreased in two; sixth, uric acid increased very greatly in two cases 
and diminished in four. Dr. Eugene I. Duchesne ( Inaug. Biss., Paris, 
1885) found that the iodide of potassium and the tincture of iodine 
notably increased the elimination of urea, while iodide of sodium was 
followed by a distinct decrease of this excretion. All the preparations 
of iodine used increased the elimination of uric acid. 

Therapeutics.— As an alterative, iodine is of especial value in chronic 
scrofula. In those cases in which there is indolent enlargement of the 
lymphatics, which exhibit no tendency, or but little tendency, to sup¬ 
purate, it is of especial value. Except in very acute cases, however, it 
should always be tried, even when the glands do tend towards suppu- 
i-ation, especially as it exerts a very beneficial influence upon the ulcers 
left after suppuration. In other forms of scrofulous disease, in chronic 
enlargements of the joints, and hone-affections of such nature, iodine is 
often of great service. As scrofulosis is generally, if not always, asso¬ 
ciated with lowered nutrition and with anaemia, cod-liver oil and iron 


* Quoted by S6e. 



ALTERATIVES. 


533 


in some form should usually be administered as adjuvants. At the same 
time that the drug is exhibited internally in these cases, its ointment 
should be freely applied to the enlarged and indurated glands. Expe¬ 
rience has demonstrated the value of iodine in goitre, whether of the 
ordinary variety or of that known as exophthalmic goitre, or Graves's 
disease. All tumors of the thyroid body are not goitre, however; cystic 
degeneration of it is very common, and is in no wise benefited by 
iodine. It is in simple hypertrophy of the gland that iodine used in¬ 
ternally and applied externally over the tumor is beneficial. During 
the acute stage of enlargement the use of leeches is often of great 
benefit, and whenever much tenderness exists should precede the exhi¬ 
bition of the drug. In phthisis , iodine sometimes does good, but only 
in the most chronic cases; and inhalations of its vapors, as have been 
recommended by Piorry, can only be of service by stimulating the 
bronchial mucous membrane and the surfaces of cavities. When soften¬ 
ing is progressing and the lung breaking down, iodine sometimes ap¬ 
pears to hasten the process. 

Local Application .—As a simple counter-irritant, iodine is very fre¬ 
quently employed when it is desired to maintain a mild, persistent influ¬ 
ence, as in chronic rheumatic affections and sometimes in phthisis. For 
this purpose the tincture is generally preferred, and it should be applied 
freely once or twice a day, or every other day, according to the suscepti¬ 
bility of the patient’s skin. In various affections of the skin, iodine has 
been employed with asserted advantage. In erysipelas of the skin, very 
beneficial results have been ascribed to its local use, and, I think, with 
justice; but great care' is necessary lest it be applied too strong. I 
have seen very serious results from the destruction by it of the skin in 
this affection. If the full strength of the tincture be used, it should 
he applied at first very lightly, and not more than once in the twenty- 
four hours. In psoriasis, in acne, in parasitic skin-diseases, it has been 
used, but holds only a second rank among remedies. In a similar man¬ 
ner it is employed in various chronic diseases of the mucous membranes, 
such as ozeena, leucorrhcea, chronic cystitis, chronic dysentery, and scrofu¬ 
lous ophthalmia, —whenever, iu a word, an alterative, stimulant action 
is desired. In cases of retraction of the gums, with consequent loosen¬ 
ing of the teeth, Professor Stille recommends the application, with a 
camel’s-hair brush, after each meal, of a watery solution (gr. i to fgi) 
of iodine, the mouth being immediately afterwards washed. The most 
important external use of iodine is as a resolvent in cases of indolent 
glandular hypertrophic enlargement, and where there are large watery 
exudations, as in some forms of chronic pleurisy and of diseased joints. 

Iodine has been very largely employed by injection into serous cysts, 
as in hydrocele, for the purpose of exciting inflammation and causing 
obliteration of their cavity; but this use of it is purely surgical, and 
the reader is referred to treatises upon such subjects. In chronic 
empyema, the injection of iodine after free exit has been given to the 


534 


GENERAL REMEDIES. 


pus is often of the greatest service. The solution in the beginning 
should be very weak, containing not more than six grains each of iodine 
and of iodide of potassium in a pint of water; with this the pleura 
should be daily washed out, the strength of the solution being gradually 
increased. 

Administration. —Iodine is never administered in solid form; nor 
should the tincture be given internally, because the iodine is precipitated 
by the watery juices of the stomach. As the iodide of potassium holds 
the iodine in solution, this preparation may be freely diluted without 
precipitation, and may even be used Irppodermically, as suggested by 
Professor Da Costa ( Amer. Journ. Med. Sci., Jan. 1875), in glandular 
enlargements. The dose is ten to fifteen drops well diluted. 

The only preparation of iodine for internal use is Liquor Iodi Com¬ 
posite—Compound Solution of Iodine — Lugol's Solution (Iodine, 1 part; 
Iodide of potassium, 2 parts; Water, 17 parts),—dose, gtt. v to xv. 

For external use, there are a tincture ( Tinctura Iodi, 1 to 12.5), and 
an ointment (Unguentum Iodi: Iodine, 4 parts; Iodide of potassium, 1 
part; to 100). 

POTASSII IODIDUM—IODIDE OF POTASSIUM. U.S. 

This salt occurs in white or colorless, generally cubic, crystals, solu¬ 
ble in two-thirds of their weight of water and in from six to eight parts 
of rectified spirits. If to its solution starch be added, no blue color 
should arise, but on the passage of chlorine the characteristic iodine 
reaction should take place, owing to the liberation of the metalloid by 
the gas; or if sulphuric acid be added, a purple tint gradually appears, 
and deepens into blue: a spontaneous blue color betrays the presence 
of the iodate of potassium, a harmful adulteration. At a dull red heat 
iodide of potassium fuses into a crystalline mass; by a bright heat it is 
decomposed. 

Physiological Action.— Iodide of potassium influences nutrition in 
a manner similar to iodine: indeed, most authorities teach that their 
action is identical; yet in therapeutics they find a different range of 
employment, and, I believe, act differently. Dr. I. Wallace ( Liverpool 
Med. and Surg. Rep., 1871) has found that the iodide lessens the elimi¬ 
nation of lime salts through the kidneys; but his analyses were not 
sufficiently repeated to prove that this is a constant effect.* 

Therapeutics. —In certain forms of rheumatism, iodide of potas¬ 
sium is of great value. In the early, active stages of inflammatory 
rheumatism it is useless; but later, when the joint-symptoms persist 
in a subacute form, the iodide comes very well into play. In sub¬ 
acute or muscular rheumatism the iodide is an efficient remedy. Often 


* For a research upon the physiological action of large amounts of iodide of potassium 
injected into the blood, see Arbeiien aits dem Pharmak. Laborator. zn Moskau, i. 125. As it 
does not seem to throw much light upon the therapeutic use of the drug, it is not here analyzed. 



ALTERATIVES. 


535 


when the symptoms are very acute it may be advantageously com¬ 
bined with the alkalies, and in lingering cases, especially where there 
is reason to suspect a gouty taint, with colchicum. In sciatica , in lum¬ 
bago , in rheumatic neuralgia following exposure to cold or wet, as in 
all other forms of subacute rheumatism, very much is to be hoped 
for from its use. In gout it is of less service than in rheumatism, but 
in the chronic form of the disease, and in the irregular, inherited gout 
which so frequently appears as neuralgia or other anomalous affection, 
it adds to the efficiency of small continuous doses of colchicum. In 
rheumatic gout , or rheumatoid arthritis , it should be tried; although little 
is to be hoped for from its use. There is a good deal of clinical testi¬ 
mony as to the value of iodide of potassium given continuously between 
the paroxysms of asthma. This disorder appears at times to bear a 
close relation to irregular gout or rheumatism, and it is probably under 
these circumstances that the remedy is efficient. In tertiary syphilis, 
including in the term all cases of syphilitic bone, visceral, or nervous 
disease, the remedy is really of inestimable value. It must be given 
freely, and, when there is no cachexia, may be advantageously com¬ 
bined with the bichloride of mercury. It is scarcely in place here to 
enumerate all the forms which tertiary syphilis may assume; but the 
iodide is useful wherever the dyscrasia has existed for a length of time. 

The iodide of potassium appears to have the power of promoting 
absorption of serous fluids, and certainly is of value in chronic pleuritis 
with effusion, in chronic pericarditis, and even in chronic hydrocephalus. 

In aortic aneurism large doses of iodide of potassium with continuous 
rest in the horizontal position have been used by Dr. Balfour (Edinburgh 
Med. Journ., xiii., xiv., xv., xvi.; British Med. Journ., 1874, i. 112) with 
results that warrant a further trial. Dr. T. S. Sharpe has claimed suc¬ 
cess from its employment in chronic Bright’s disease (ff mer. Journ. Med. 
Sci., Jan. 1876). 

In various chronic metallic poisonings the iodide of potassium is of 
great service. With both lead and mercury it forms double salts, which 
are soluble, and there is very good reason for believing that the forma¬ 
tion of these salts takes place in the economy, and that the metal which 
has been lying in an insoluble condition in the various tissues is taken 
up and excreted. Severe salivation and ulcerative stomatitis have 
sometimes resulted from the use of the potassium salt in those v T ho 
had previously taken large quantities of mercury;* and in Melsen’s 
experiments, dogs to which insoluble preparations of mercury had pre¬ 
viously been given without the induction of severe symptoms after¬ 
wards died under the action of the iodide, the mercury also having 
appeared in their urine. The experiments of Mayengon and Bergeret, 
quoted in the article on Mercury, afford striking confirmation of 
these facts, and seem to render the evidence irresistible that the iodide 


* See Dr. Budd, Brit, and For. Medico- Chir. Rev., xi. 202, for a striking ease. 



536 


GENERAL REMEDIES. 


does cause the elimination of mercury. In regard to lead, the re¬ 
searches of Drs. Parkes, Goolden, Swift, Melherbe, Sieveking,* and 
Marshall ( Therap. Gaz ., Feb. 1S88) have shown that very frequently 
in cases of chronic lead-poisoning the exhibition of iodide of potas¬ 
sium causes the appearance of lead in the urine. This chemical evi¬ 
dence is abundantly corroborated by clinical experience, so that in all 
cases of chronic metallic poisoning the persistent use of the iodide of 
potassium should be tried. 

Administration.— The ordinary dose is ten grains three times a day; 
but much larger quantities may often be given with impunity, and, in 
internal syphilitic affections, may be necessary. In the latter class of 
diseases, the best plan is to begin with twenty grains three times a day, 
and rapidly to increase the amount until drachm doses are reached, or 
frontal pain or other symptom of iodism produced. The best substance 
for disguising the very disagreeable taste of the drug is the compound 
syrup of sarsaparilla. Unguentum Potassii Iodidi , U.S., contains about 
one-eighth its weight of the iodide. 

Liquor Arsenii et ITydrargyri Iodidi, U.S. — Solution of the Iodides 
of Arsenic and Mercury contains one per cent, each of the iodide of arsenic 
and the red iodide of mercury. It was originally suggested by a sur¬ 
geon of Dublin, by whose name it is very generally known. Donovan's 
Solution is a powerful alterative, used chiefly in very obstinate chronic 
scaly skin-diseases , when the local action is of a very low grade, and 
in chronic rheumatism. It is an exceedingly active preparation, very 
capable of acting as a corrosive poison, and when administered a little 
too freely is said sometimes to cause salivation. When applied locall}', 
it acts as a violent irritant. The dose of it is from three to ten drops, 
well diluted. 

IODOFORMUM—IODOFORM. U.S. 

This substance was discovered by Serullas in 1822, and was intro¬ 
duced as a remedy by Dr. Glover in 1837, but did not become officinal 
until the 1880 revision of the U.S. Pharmacopoeia. It occurs as small, 
pearly-yellow crystals, having a strong, persistent, saffron-like odor, 
insoluble in water, but readily soluble in alcohol and in ether. 

Physiological Action.— According to M. Maitre, when taken by 
man in doses of five or six grains iodoform causes no notable symptoms, 
but two hours after the drug has been ingested, iodine can be found in 
the urine. The extensive surgical use of iodoform has led to a number 
of poisonings by it. The symptoms are variously described, and it is 
almost certain that in some cases they have been due to the wound and 
not to the dressing. They may be preceded by general malaise for a 
day, and then suddenly burst forth (case, Deutsch. Med. Wochenschr., ix. 
443). In the most characteristic and severe class of cases the phe- 


* See Still6’s Therapeutics , vol. ii. p. 735, Blanchard and Lea, 1864. 



ALTERATIVES. 


537 


nomena resemble somewhat those of meningitis, and may be somnolence, 
deepening into stupor, with contracted motionless pupils, or restlessness, 
ending in active delirium, in either case the temperature being normal 
and the pulse exceedingly rapid. A peculiarity of these cases seems to 
be that death usually follows, although the symptoms have developed 
abruptly and the dressings have been removed at once. Dr. Schede, 
of Hamburg, describes six classes of cases, his sixth form being that 
just spoken of. 1. High fever, without other phenomena. 2. Fever, 
with mild gastro-intestinal irritation, depression of sjoirits, and rapid 
pulse; recovery almost invariable. 3. Yery rapid, soft pulse, 150-180, 
no fever; great danger. 4. Yery rapid pulse, with high fever; death 
almost invariable. 5. After severe operations, rapid collapse and death. 
A form of poisoning with melancholia, dilated pupils, and hallucinations 
is also described. A roseola-like dark-red eruption has been noted in 
some cases of poisoning, and even when the constitutional symptoms 
are very slight there may be an extensive erythema. (Cases, Intern. 
Cong. Copenhagen , 1884, Sect. Dermatol., p. 118.) 

The action of iodoform upon the lower animals has been investigated 
by a number of observers, but to complete our knowledge further re¬ 
searches are necessary. The sjunptoms in the frog are said to be mus¬ 
cular relaxation with sometimes, at a later stage, convulsive movements. 
In the higher animals large but non-toxic doses produce symptoms of 
intoxication, tottering, weakness, and loss of appetite, but no vomiting; 
fatal doses cause anaesthesia, narcosis, convulsions, with violent opis¬ 
thotonos, hurried or irregular breathing, slow, feeble pulse, and finally 
death. A. Hoyges found that in dogs and cats toxic doses caused 
deep sleep without loss of reflex activity, but that in rabbits no sleep 
resulted ( Arch. f. Exper. Pathol, u. Pharrn., x. 405). Yery frequently 
after these large doses, especially when they are repeated, there is great 
gastro-intestinal disturbance, as is shown by vomiting, diarrhoea, and 
dysentery, with bloody discharges. The action of the drug upon the 
circulation has been especially studied by M. Eummo (Arch, de Physiol. 
Norm, et Pathol ., 1883, 144). He finds that in the frog the rate of the 
cardiac pulsations is lessened, and for a time the energy of the ventric¬ 
ular systole is increased, but afterwards the pulsations become feeble, 
and finally the heart is arrested in diastole; the contractions cannot be 
re-established by the use of atropine. In the mammal, the rate of the 
pulse is decreased, and after small doses the arterial pressure at first 
increased. By large doses the pressure is much diminished. Section 
of the pneumogastrics does not affect the cardiac action of the drug. 
M. Rummo finds that iodoform acts first upon the nerve-centres, and 
finally upon the trunks of the nerves and upon the muscles. After 
very large doses there is albuminuria and even hrematuria. 

After death from iodoform a very wide-spread fatty degeneration 
is to be found. This change appears to commence in the liver and 
rapidly to involve all tissues of the body. M. Floucaud ( These de Mont - 


538 


GENERAL REMEDIES. 


pellier , 1872) states that there is a very distinct alteration of the blood- 
corpuscles. 

By the alimentary canal iodoform is absorbed very slowly; from 
wounds it is taken up with comparative freedom. Zeller believes 
(Zeitschrift fur Physiolog. Chemie , viii. 70) that there is always an albu¬ 
minous compound of iodine formed at the seat of absorption. The 
iodine escapes from the body by all the secretions as well as by the 
breath, partially as an iodide, partially as an iodate, and partially in 
the form of a new organic compound of iodine.* According to the 
researches of M. Rummo, the elimination of iodine commences within 
one hour after the stomachic ingestion of the iodoform, and goes on so 
slowly that the haloid can be found in the urine three days later. 

It is probable, as Professor Binz teaches, that iodoform acts by 
liberating iodine in contact with the tissues, since Moeller has found 
that the iodates and iodic acid cause similar symptoms ( Inaug. Diss., 
Bonn, 1877), and Dr. Schwerin has shown that methyliodide is also 
anaesthetic and hypnotic ( Centralbl. f. Med. Wissensch., 1884, 146). 

When iodoform is applied in strong solution, or in substance, it 
acts as a very powerful local anaesthetic. Thus, a suppository contain¬ 
ing it, if introduced into the rectum, will so benumb the parts that 
defecation may take place without the person or animal being aware 
of it. 

Therapeutics. —Iodoform has been used internally as an alterative 
and analgesic in syphilitic rheumatism and night-pains , and in other forms 
of neuralgia. Dr. Stiles Kennedy highly commends it {Med. and Surg. 
Rep ., Jan. 1870, p. 50), and Lazansky finds it very useful in some cases 
{Centralbl. f. Chirurgie , 1876, 219), but that it fails in others; he gives 
ninety grains a day. Dr. J. Moleschott {Lond. Med. Record , Nov. 1878) 
praises it most highly as an absorbefacient, affirming that by its use ho 
has obtained absorption of various lymphatic tumors, pleuritic, peri¬ 
cardiac, and other effusions, and has even cured acute hydrocephalus and 
leukcemia. He relies especially upon its external employment in the 
form of a collodion (1 part of iodoform, 15 of elastic collodion). As 
soon as the collodion has dried, he covers it with a film of solution of 
gutta-percha. Dr. Yon Iloffer has used it hypodermically (three to 
five grains a day) in syphilis, and asserts that so employed it greatly 
increases the number of the red corpuscles. Dr. E. Thomann also bears 
testimony to the value of these hypodermic injections in secondary 
syphilis {Centralbl. f. Med. Wissen ., Oct. 1881). Iodoform, however, has 
not come into general use as an internal medicine, and, in the extensive 


* For an important bibliography, see the paper of M. Rummo. For details as to elimina¬ 
tion and discussion of methods of finding the iodine in the urine, consult Johannes Grundler, 
Schmidt’s Jahrb., ccii. 232; Professor Harnack, Berlin. Klin. Wochenachr., 1S83, No. 47, 
also Zeita. f. Phyaiol. Chem., viii. 158, 1884; A. Zeller, Arch. f. Klin. Chir., xxviii. 590; Dr. 
E. Baumann, Schmidt’a Jahrb., ccii. 233; Verhandl. Deutach. Geaell.f. Chemie, Berlin, 1882, 
xi. 219. 



ALTERATIVES. 


539 


trials made with it at the Philadelphia Hospital, has failed to sustain 
its first reputation in syphilitic disorders. 

Whatever position iodoform may finally acquire as an internal rem¬ 
edy, there can be no question as to its value when employed locally. 
It is useful in cases of painful ulcers, even when they are cancerous ,* 
serving to alleviate pain and to promote cicatrization. At first em¬ 
ployed especially in syphilitic affections, it is now found to act equally 
well in indolent leg-ulcers and other non-specific abrasions, and is thought 
to act not only as a local amesthetic, but also as a decided stimulant to 
nutrition. Within the last few years it has been very freely employed 
as an antiseptic dressing to wounds, and the testimony is so strong that 
it is difficult to avoid believing that it is the most certain remedy of 
this class. It is, however, affirmed to have no power in preventing 
erysipelas, and used freely is very dangerous to the patients. It is 
employed either in the form of powder dusted in the wound, or as 
dressings saturated with it, the first method being at once the more 
effective and the more dangerous. The quantity required to take life 
is uncertain. Dr. Langenstein attributes a death to four grammes 
(Wien. Med. Wochenschr., 1882, xxxii. 1051). The cause of death seems, 
however, doubtful. Dr. Czerny reports death from six grammes, not 
doubtful (Ibid., p. 180). 

The good results which have followed the surgical use of iodoform 
as an antiseptic dressing have led to a series of investigations as to its 
action on the lower organisms, with results which are apparently at 
variance with previous surgical teachings. In November, 1886, De 
Ruyter announced at a meeting of the Berlin Surgical Society that 
the powder of iodoform has little or no effect in preventing the devel¬ 
opment of bacteria, and that when it is mixed with rapidly-infective 
bacteria, like those of anthrax, it does not sensibly influence the develop¬ 
ment of the disease which is caused by inoculation with the mixture. 
This has been confirmed experimentally by Dr. Kronacher (Munchener 
Med. Wochenschr., 1887, xxxiv. 546), who employed the bacteria of erysip¬ 
elas and of anthrax ; also by P. Baumgartenf (Berlin. Klin. Wochenschr .), 
who further found that iodoform powder mixed with the tubercular bacil¬ 
lus in cultivating apparatus did not prevent its ordinary development, 
and that the bacillus mixed with iodoform powder when introduced 
into guinea-pigs and rabbits produced rapid tuberculosis; also by Dr. 
Liibbert (Fortschritte der Med., v. 343), with the Staphylococcus pyo- 


* Consult papers by Dr. G. Volker ( Bulletin de ThSrapeutique, t. Ixxiii., Deo. 1867) and 
Dr. F6r6ol (Ibid., t. lxxiv., May, 1868). The surgical reader may consult with advantage 
the following additional references : Correep.-Blatt f. Schweiz. Aertz., 1882, xii. 609; DeuUch. 
Med. Wochenschr., Berlin, 1882, viii. 146; Centralbl.f. Chirurgie, viii. 755, ix., various papers; 
Journ. Med. de Bordeaux, xi. 205; Allgem. Wien. Med. Zeitung, 1881, xxvi. 455; Wien. Med. 
Presse, 1882, xxiii. 201. 

j- A curious fact made out by Baumgarten was that rubbing the bacillus of anthrax with 
any hard powder apparently mechanically kills the organism. 



540 


GENERAL REMEDIES. 


genes; also by Drs. Chr. Heyn and Thorkil Drovsing ( Fortschritte der 
Med., v. 33), who found that iodoform has no influence upon the de¬ 
velopment of Staphylococcus pyogenes or of the coccus of pneumonia 
or of the Bacillus subtilis and other organisms, and conclude that it 
is not only worthless as an antiseptic, but may even be the means of 
carrying the septic organisms into the system ; also by Dr. Johan Olsen 
{Norsk Magazin for Lcgevidensk ., 1886), with various bacterial organ¬ 
isms; also by Konige ( Therap. Monatshefte, April, 1887). On the other 
hand, Dr. H. Sattler ( Fortschritte der Med., v. 362), in his exjjeriments, 
found that when he impregnated threads with iodoform and micro¬ 
organisms and then placed them in culture-apparatus, the iodoform had 
a very distinct effect in checking the development of the bacteria, and 
De Buyter states that if instead of using the iodoform poAvder he 
employed an ethereal solution in which decomposition of the iodoform 
had already commenced, there was a distinct effect upon the organisms. 
In a further series of experiments De Rujder showed that iodoform is 
decomposed by blood, serum, and other organic fluids in which micro¬ 
organisms are growing, and apparently proved that the decomposition 
is produced by the ptomaines developed by the growing organisms. 

The clinical results achieved by surgeons are so concordant and so 
decided that the practical value of iodoform in the treatment of wounds 
and ulcers must be considered established. It is possible that a part 
of the good influence of the iodoform is due to a specific effect upon 
the tissues of the wounds. Further, the powder of iodoform may have a 
very distinct protecting power both mechanically and by the dryness 
of the wound which it maintains, the discharges from the wound being 
the especial soil in which the bacteria develop. In certain cases, espe¬ 
cially in tubercular diseases, iodoform appears, however, to exert an influ¬ 
ence greater than can be accounted for by this indirect action. Many 
clinicians bear strong testimony to the effect of iodoform on tubercular 
ulcers of the larynx and other organs. Professor Bruns ( Therap. Monats¬ 
hefte, May, 1887) relates fifty-four cases of cold tubercular abscesses 
treated by evacuation through aspiration and a subsequent injection of 
a ten-per-cent, mixture of iodoform, glycerin, and alcohol, with closure 
of the orifice made by the needle by means of the iodoform collodion. 
Of fifty-four such cases forty were healed,—many of them as the re¬ 
sult of a single injection. For the purposes of study, some of the 
abscesses were opened, and tubercular bacilli were found abundant in 
their walls. According to Professor Bruns, the first change which 
results from the iodoform is the disappearance of the tubercular bacilli 
and the appearance of normal granular tissues. In De Ruyter’s ex¬ 
periments, already quoted, the products of the decomposition of iodo¬ 
form distinctly checked the growth of organisms, and it is at present 
most probable that some of the results achieved by iodoform as a topical 
application are due to the long-continued antiseptic influence of the 
iodine compounds slowly formed by its decomposition. 


ALTERATIVES. 


541 


Administration.— Iodoform may be applied to ulcers in powder, in 
solution, or in ointment ( Unguentum Iodoformi —1 to 10, U.S.). When 
there is a great deal of pain, especially if there be much discharge, the 
powder may be preferred. In uterine cancer , in painful hemorrhoids , 
cacao butter suppositories, containing from five to ten grains of the 
drug, should be employed. Owing to the bad odor of the drug, its 
application about the mouth and throat is often objected to. Accord¬ 
ing to Dr. Lewis Elsberg ( Phila. Med. Times , Oct. 4, 1873, vol. iv. p. 4). 
if to four parts of absolute ether one part of crystallized iodoform be 
added, and the whole shaken in a red, glass flask, a solution is obtained 
of sufficient strength for effectual use in diseases of the mouth, and 
free from odor other than that of ether. 

IODOL. 

Iodol, which is made by the action of iodine upon pyrol, is a yel¬ 
lowish-brown, shining powder, composed of long, prismatic crystals 
soluble in three parts of absolute alcohol, in ether, and in fatty oils, but 
soluble in water only in the proportion of one to five thousand. It is 
tasteless and without odor. It contains 88.9 parts per hundred of iodine, 
as contrasted with 96.7 parts contained in iodoform. First discovered 
by Silber and Ciammican, it was proposed as an antiseptic by Dr. Gr. 
Mazzoni, of Rome ( Berlin. Klin. Wochenschr ., 1885). The experiments 
made with it upon the lower animals by Dr. Marcus ( Berlin. Klin. 
Wochenschr ., 1886) and by T. Pahl ( Inaug. Kiss., Berlin, 1886) show 
that when given in sufficient dose to animals it causes emaciation, albu¬ 
minous urine, fall of temperature, general loss of muscular power, and 
finally death from fatty degeneration of the liver, kidneys, and other 
tissues. It has been asserted by surgeons that iodol is not capable 
of producing constitutional symptoms. The experiments just quoted 
show, however, that this is not correct. Moreover, in a ease reported by 
Dr. C. Lanenstein ( Therap . Gaz., 1887, 768, from the Swedish) the use 
of the drug as a surgical dressing caused dizziness, marked rise in the 
temperature, vomiting, small irregular pulse of 136, albuminous urine, 
and apathy, which did not subside for four days. Iodine was found 
in the urine for two weeks. In the experiments of Seifert, iodine was 
first detected in the urine and saliva twelve hours after the ingestion 
of seven and a half grains, did not reach its maximum until eighteen 
hours, and continued present for three full days : this accords with the 
statement of Pick ( Viertelj. f. Kermat. u. Syph., 1886) that iodol is ab¬ 
sorbed very slowly. This slow absorption is probably the reason that 
it is a less dangerous topical application than is iodoform. 

Therapeutic Use.— Iodol may be employed for all purposes for 
which iodoform has been used. It has been found very valuable in the 
treatment of tubercular laryngitis , and may be blown into the larynx 
directly upon the ulcers without causing irritation. It has been used 
by Pick very freely as a local application in the treatment of blennor- 


542 


GENERAL REMEDIES. 


rhagic and simple vaginal catarrh , as well as in chancres and other ulcers, 
and in suppurative adenitis. Various surgeons have employed it as a 
substitute for iodoform in the treatment of wounds, and the testimony 
as to its value is concordant. Mazzoni’s original solution was—iodol 
1 part; alcohol 16 parts ; glycerin 34 parts. One drachm of iodol forms 
with one ounce of ether a clear brown solution, which may be applied by 
the spray or brush to the nasal and other mucous membranes, upon 
which it leaves a coating of iodol. Iodol pastilles are prepared by Dr. 
Wolfenden from one grain of iodol, one minim of glycerin, and eigh¬ 
teen grains of glyco-gelatin, and are by him strongly recommended 
for laryngitis. Iodol has also been used as an internal remedy. Dr. 
Assaky states that its effects in tertiary syphilis and scrofulous affec¬ 
tions are extraordinary. The usual dose is two or three grains a day; 
but Assaky gave from six to thirty grains a day, and Pick asserts that 
he has given from thirty to forty-five grains a day, and that only in 
rare cases was there diarrhoea produced or any evidence of constitu¬ 
tional affection ( Therap. Monatshefte , No. 1 , 1887). 

OLEUM MORRHU^E—COD-LIVER OIL. U.S. 

Cod-liver oil is obtained from the liver of Gadus morrhua and other 
species of Gadus. In the manufacture of the so-called shore oil, the 
only variety usually employed in medicine, the fish caught near land 
are brought at once to the shore, and the oil is obtained from the fresh 
livers by one or other of several processes. The original custom was 
to put the livers into large kettles, add water, boil to a pultaceous mass, 
drain off the liquid, allow it to stand, and finally to skim the oil as it 
rose to the top. A more modern method is to heat the livers by steam 
applied to the outside of the vessel containing them, to allow drainage, 
and to proceed as in the process just described. I am informed that at 
present some of the finest brands of oil are prepared by forcing cur¬ 
rents of steam at high pressure through the mass of livers, tearing 
them in this way to pieces, and melting out their oil. Shore oil should 
be a perfectly limpid, yellow, thick oil, free from rancidity, and having 
the peculiar taste and smell of the oil well developed. Straits oil or 
Banks oil is prepared from those fish caught at the “ Banks,” for from 
land. 

The livers are thrown into casks and allowed to stand for a greater 
or less length of time and to undergo more or less complete putrefac¬ 
tion, until, on the return of the fishing-smack to port, they are thrown 
into water-boilers and treated in a manner similar to that previously 
described. Of straits oil there are two varieties: the brown oil, which 
is much darker than shore oil, and much more nauseous to the taste 
and smell; and the black oil, which is very dark, and still more disgust¬ 
ing in its evidences of rancidity. Both of these varieties are largely 
used in the preparation of leather. 

When a mineral acid (especially the sulphuric) is added to cod-liver 


ALTERATIVES. 


543 


oil, the well-known biliary play of colors occurs; but this does not 
prove the genuineness of the drug, or demonstrate that it is derived 
from the codfish: it only shows that it is a liver oil. It is scarcely to 
be doubted that not rarely the livers of other fish are largely mixed 
with those of the Gadus morrhua, but it is not probable that this often 
happens to such an extent as to interfere with the therapeutic value of 
the product: indeed, it is far from certain that cod oil is really superior 
to that produced by the same organ of other fishes. Be this as it may, 
the physical properties afford the only known test as to the genuine¬ 
ness of the drug. Cod-liver oil is a very complex substance, contain¬ 
ing, according to the analysis of De Jongh, glycerin, oleic, margaric, 
butyric, and acetic acids, gaduin, various biliary principles, such as fel- 
linio, cholic, and bilifellinic acids, iodine, chlorine, traces of bromine, 
phosphorus, phosphoric acid, and various other substances. According 
to the U.S. Dispensatory, the proportion of iodine never exceeds one 
part in two thousand. In De Jongh’s analysis the greatest amount 
was found in the light-colored oils, and was only four-hundredths of a 
grain in one hundred grains of the oil. Gaduin is a peculiar, dark-brown 
substance, which is probably medicinally inert. When to cod-liver oil 
ammonia is added, there can be obtained, by distillation, a peculiar 
ammoniacal base, trimethylamin (commercial propylamin), which exists 
in no other officinal oil, but occurs in the ergot. 

Physiological Action.— As is well known, all fatty substances when 
taken into the system have a tendency to cause deposition or formation 
of fat in the body. Cod-liver oil cei*tainly shares this property in an 
eminent degree. Dr. Pollock, as quoted by Professor Stille, has found 
that if there be given of it to pigs from one to two ounces per diem, to 
sheep one ounce, and to bullocks from three to nine ounces, it is di¬ 
gested, and aids in fattening the animal; larger amounts than those 
noted in Dr. Pollock’s experiments always derange very seriously the 
digestive function. No close studies of the effect of cod-liver oil upon 
healthy men have, that I am aware of, been made. Undoubtedly it 
tends to produce obesity; but, as no other oil is able to supply its place 
in various chronic diseases, it must have some influence upon nutrition 
not shared by ordinary fatty matters,.,and therefore is an alterative. 

The history of the clinical use of oleum morrhuse certainly indicates 
that it influences the constitution of the blood. It is an every-day 
occurrence to see pale, amende patients become, while taking it, rosy 
and plethoric. According to the analysis of the blood of a patient 
made by Simon, there is, during its use in phthisis, a great increase in 
the amount of solids in the blood, a diminution of the fibrin, and an 
increase in the albumen. The examinations of Dugald Campbell ( British 
and Foreign Med.-Chir. Review , 1856, xvii. 21) have confirmed the re¬ 
sults of Simon. It is very probable that cod-liver oil has some pecu¬ 
liar influence upon the blood-making organs. Upon the various single 
functions of the body, except the digestive, cod-liver oil has no apparent 


544 


GENERAL REMEDIES. 


immediate effect, disturbing directly neither the nervous, motor, respi¬ 
ratory, circulatory, nor secretory movements. When by its use the 
general nutrition is improved, all the functions seem to share equally 
in the improvement. Cod-liver oil has undoubtedly, when given with 
sufficient freedom, a tendency to cause indigestion and looseness of the 
bowels. All oils are of difficult digestion, and when too much of the 
oleum morrhuae is exhibited in man, as in animals, it exerts a delete¬ 
rious local effect upon the alimentary apparatus. 

Much speculation has been indulged in as to which of the ingredients 
of cod-liver oil impart to it its peculiar medicinal properties. Certainly, 
however, no real light has been shed upon this matter, and the present 
probabilities are that it acts as a whole,— i.e., that its virtues depend 
upon the peculiar combination. 

If the experiments of Dr. Oswald Naumann (Archiv der Heilkunde , 
1865, p. 536) be as accurate as they appear, he has certainly proved 
that cod-liver oil has physical properties which must aid in its useful¬ 
ness, although it is not probable that its value depends solely, or even 
in great part, upon them. He first tested the rate at which various 
oils pass through fresh moist animal membranes when pressed upon by 
a column of mercury or by the weight of the atmosphere over an ex¬ 
hausted receiver, and found that cod-liver oil passed much more rapidly 
than any of a number of oils tried. Apparently this power depended 
in some measure upon the presence of the biliary principles, since if it 
was deprived of them the rate of its passage was greatly lessened, but 
was again increased by the addition of a little bile. The investigator 
then, opening the abdomen of cats, separated in each animal by liga¬ 
tures two knuckles, of equal length and entirely similar, from the 
remainder of the intestines. Into each of them he injected a certain 
amount of bile, and then into one ordinary oil, into the other cod-liver 
oil; and when the animals died, some hours afterwards, it was always 
found that much more of the cod-liver oil was absorbed than of the 
other oil. These experiments were, unfortunately, too few and incom¬ 
plete to be decisive, but certainly they indicate that oleum morrhuse 
is more easily and rapidly absorbed than other animal oils. The supe¬ 
rior fitness of the oil for absorption is in accord with the clinical obser¬ 
vation of M. Berthe ( L ’ Union Med., x., 1856), that cod-liver oil could 
be taken longer than other fats without appearing in the fffices, and is 
confirmed by Professor Bucheim (Arch. f. Exper. Path. u. Pharm., Bd. 
iii.), as well as by J. Gad (His und Braune's Archiv fur Anatomie, 1878). 
Both Bucheim and Gad believe that this absorbability depends largely 
upon the presence of free fatty acids in the oil, but it is probably due 
to the biliary matters, since Dr. H. A. Hare finds it greatly increased 
by the addition of taurocholate and glycoeholate of sodium (Bost. Med. 
and Surg. Journ ., cxvi. 279). He asserts that cod-liver oil impregnated 
with a small quantity of the biliary salts is rapidly absorbed when 
rubbed upon the skin, and proposes the practical use of the mixture. 


ALTERATIVES. 


545 


Dr. Haumann’s last scries of experiments were directed to discov¬ 
ering the comparative ease with which animal oils and the cod-liver 
oil were oxidized. For this purpose he used a test-solution of per¬ 
manganate of potassium, and on adding to given bulks of this, in test- 
tubes, equal amounts of the various oils, noted the changes of color 
induced by the reduction of the permanganate. He found that cod- 
liver oil was the first to be affected. It is evident that the power of 
being easily absorbed and easily oxidized fits a fat for use in the animal 
economy; but the peculiar value of oleum morrhuse does not depend 
solely upon these properties.* 

Therapeutics. —Cod-liver oil is especially useful in that condition 
of system in which, with general lowered tone, there is a tendency to 
cellular hyperplasia, to the formation of “ exudations” composed of 
imperfectly-developed cells, which, in the great majority of cases, from 
the very beginning are incapable of development into perfect entities, 
having only one potential quality, that of dying. There are various 
types of this diathesis, or condition of system. In one of them there 
is a tendency to increase in the lymphatic glands; to multiplication, at 
the expense of development, of their cellular elements,— i.e., to the 
formation of numerous imperfectly-developed cells,—and, finally, to the 
destruction of them. The death of these cells is partly due to their 
inherent qualities, and is partly the result of the pressure which they 
exert upon one another and upon their sources of food-supply. If 
they undergo a slow, fatt 3 r degeneration, with desiccation, cheesy de- 
jiosits are formed ; if a rapid, fatty change, with abundance of moisture, 
pus and abscesses are produced: in either case, ulceration is the final 
result. This is the so-called scrofulous diathesis,— scrofulosis. In an¬ 
other of this group of diatheses, the tendency to cellular hyperplasia 
affects the mucous membranes of the air-passages, and the patient, on 
the slightest provocation, suffers from catarrh, until finally a multipli¬ 
cation of cells occurs so rapidly as to fill up a greater or less number 
of the air-vesicles of the lungs, generally those of the apex, and “ con¬ 
sumption" results; or else, an attack of pneumonia being produced by 
some exposure, the exudation is cellular rather than fibrinous, and 
catarrhal pneumonia, ending in the majority of cases in a more or less 
rapid phthisis, occurs. 

As already stated, it is especially in these conditions of system that 
cod-liver oil is so extremely useful. Preceding the development of 
active disease in these cases there is very generally a recognizable stage, 
marked by weakness, a tendency to emaciation, more or less anaemia, 


* M. Chapoteau claims to have discovered a crystalline substance, Morrhuol, in cod-liver 
oil, containing phosphorus, iodine, and bromine. According to Dr. Lafage (Le Progrig Mid., 
Feb. 20, 1886), to this substance are due the peculiar medicinal properties of codrliver oil, and 
in tuberculosis and allied diseases it may be given in capsules containing three to five drops, 
representing one drachm of cod-liver oil. Morrhuol is said to be stimulating rather than 
disturbing in its influence upon the gastro-intestinal tract. 

35 



546 


GENERAL REMEDIES. 


and other symptoms, which the present is scarcely the place to consider 
in detail. In this stage, cod-liver oil is exceedingly efficacious, and its 
use, combined with proper hygienic measures and the exhibition of 
other suitable drugs, may often succeed in warding off fatal disease. 
In scrofulosis, it is useful in all stages, but should never be relied on to 
the exclusion of other drugs. Its effects are more marked during the 
ulcerative and suppurative stages , but in most cases it aids iodine very 
materially to reduce the enlarged glands in the earlier periods of the 
disease. 

There are various diseases of the bones, dependent upon or resulting 
from a scrofulous taint, which are most favorably affected by cod-liver 
oil. Sometimes the disease attacks the articulating surfaces, giving 
origin to chronic inflammations of the joints,— white swellings; some¬ 
times it is the body of the bones, especially of such as are composed 
chiefly of spongy tissue, that is affected, and caries , w T ith subsequent 
abscesses, results. In these, as in all other forms of scrofulosis, cod- 
liver oil is almost a specific. An affection probably not identical with, 
but closely allied to, scrofula, is rickets : cod-liver oil is of great value 
in this complaint. In certain pale cachectic children there may be 
found a swollen, tumid belly, perhaps with evident enlargement of the 
liver, and very generally, if not always, with enlargement of the mes¬ 
enteric glands. This is the so-called tabes mesenterica , which is some¬ 
times relieved, or even cured, by the exhibition of cod-liver oil. 

The value of cod-liver oil in what is often verj” incorrectly called the 
“ pre-tubercular" stage of phthisis has already been mentioned, but is so 
important that it will bear reiteration. There can be no doubt that 
consumption often commences with catarrh, and is often developed 
slowly as the result of frequently “ catching cold.” Whenever a patient 
is feeble, pale, somewhat amende, and complains of his liability to catch 
cold on the slightest exposure, even though no local disease exists any¬ 
where, or rather because no local disease exists anywhere, there is cause 
for alarm; and it is of the most vital importance that the patient be 
put upon a tonic treatment whose basis is cod-liver oil, be fed upon 
nutritious diet, and have the hygiene of his daily life regulated, especial 
care being taken to avoid any exposure to cold. In the advanced stage 
of chronic phthisis the remedy is less efficacious, in that it much more 
rarely effects a cure than in the pre-tubercular stage; yet it does more 
good than all the other remedies of the Pharmacopoeia combined,—al¬ 
leviating the cough, increasing the strength, weight, and general health 
of the sufferer, often retarding or even arresting the pulmonic disorgan¬ 
ization, almost always greatly prolonging life, and in rare instances, 
in conjunction with other measures, effecting a cure. It is a question 
of some importance to decide how the remedy does good in these cases. 
Its value, before the occurrence of any lesion, as a preventive of con¬ 
sumption, indicates that its influence during phthisis is not directly upon 
the local lesion, but upon the general condition of the system. This 


ALTERATIVES. 


547 


inference is borne out by clinical experience. The general symptoms 
commence to improve before the local lesions, and sometimes, although 
the patient fattens and gets stronger for a time, the pulmonic affection 
steadily increases; again, in some instances the oil fails to increase the 
weight of the patient or sensibly to affect the general nutrition, and in 
these cases it never does any good. In true tuberculosis , cod-liver oil, 
like all other remedies, is of very little, if any, value. 

In cases of defective nutrition , when pallor, anaemia, loss of strength, 
and, perhaps, emaciation, occur without any obvious cause, cod-liver oil 
is often of great service, especially when the subject is a child. Indeed, 
in children these symptoms are simply the result of a veiy mild action 
of the same depressing causes whose more intense malign influence 
produces scrofula. 

In persons broken down with any of those chronic diseases which 
take the form of dyscrasia, the remedy is often of great service. Thus, 
in the cachexia of tertiary syphilis it is invaluable. The disease by 
whose relief and cure cod-liver oil first achieved its reputation is chronic 
rheumatism. I think, however, that it is much more efficacious in those 
cases in which the rheumatic disease has been grafted upon a scrofu- 
lously-tainted constitution, or in those cases in which the patient has 
been broken down by the disease, or by other agencies, so that there is 
what may be styled a general nutritive dyscrasia, than in simple chronic 
rheumatism; yet in obstinate sciatica and lumbago trial of it should 
always be made. In gout, oleum morrhuse is of little service, and should 
be used only in the very chronic form of the disease, and when there 
is a generally disordered nutrition. 

In nervous affections , especially in neuralgia , in sldn-diseases, in fact, 
in any chronic disorder in which the patient is feeble and presents a 
condition of general depraved nutrition somewhat similar to that seen 
in consumption, cod-liver oil may be exhibited with advantage. 

Administration.— The dark oil has been esteemed most highly by 
some authorities, especially by De Jongh, who asserts that it contains 
more of the biliary principles than does the pale oil, and even believes 
that the products of decomposition in it increase its beneficial action. 
It is, however, never employed at present, because of its exceedingly 
repulsive taste, and because it is very prone to disagree with the stom¬ 
ach. One of the difficulties in the use of even the pale oil is the very 
common real or imagined inability of the patient to take it. Without 
doubt, this very often arises from its nauseous taste, to lessen or dis¬ 
guise which various expedients are resorted to, with more or less doubt¬ 
ful success. Sometimes a piece of salt taken into the mouth just before 
the oil, which is also immediately followed by another lump of salt, 
suffices. It is said that some prefer the oil in emulsion made with 
some strong aromatic water. The addition of an equal part of glyce¬ 
rin and one-half to one drop of the oil of bitter almonds to the dose 
certainly lessens the taste of the medicine. Some patients take it best 


548 


GENERAL REMEDIES. 


in the froth of ale or porter, the glass being first half filled with the 
malt liquor, then the oil being carefully floated on the top without 
touching the sides of the glass, and the remainder of the vehicle put 
upon the top of it. Most of the patients requiring oil are also benefited 
by the use of alcohol; and my experience with the remedy is that the 
most generally successful plan of exhibition is to place, according to 
the exigencies of the case, from one to three tablespoonfuls of whisky 
or brandy in a tumbler, add not so much water, put the oil in the centre, 
and toss the whole down the throat, the head being held well back, the 
mouth wide open, and the lips not touched by the medicine. The 
stimulus of the alcohol often enables the stomach to digest the oil 
when otherwise it could not do so. Sometimes it is necessary to com¬ 
mence with a single small daily dose, even a single teaspoonful, which 
is best taken at bedtime, and gradually to increase the amount as the 
patient becomes habituated to it. Children almost always learn to 
tolerate the taste of the oil, or even become in a short time fond of it. 
The usual dose is for an adult a tablespoonful three or four times a 
day; for a child one year old, a teaspoonful. When infants cannot 
digest cod-liver oil, inunctions may sometimes be practised with advan¬ 
tage. Drs. N. A. Randolph and A. E. Roussel state that they have 
seen in such cases the oil appear in the faeces ( Phila. Med. Times , xiv. 
239). 

ACIDUM PHOSPHORICUM-PHOSPHORIC ACID. U.S. 

Phosphoric acid, which results from the burning of phosphorus in 
the air, is prepared by the action of sulphuric acid upon bone-ash, which 
consists chiefly of the phosphate of calcium. The officinal acid is the 
tribasic acid of chemists. Acidum Phosphoricum Dilutum, U.S., con¬ 
tains twenty per cent, by weight of the stronger acid. It is a color¬ 
less, inodorous, sour liquid, of a syrupy consistence, which has a very 
acid reaction, but is not corrosive to animal tissues. The bibasic 
pyrophosphoric acid is said to be a cardiac sedative (Journ. of Anat. and 
Physiol ., xi.). 

Therapeutics. —Phosphoric acid has been used to a considerable 
extent abroad as a tonic and alterative in scrofulous affections. Upon 
the digestive organs, in my experience, it has little or no effect, and I 
have never been able to perceive that it is at all astringent or exerts 
any alterative influence upon the glands of the alimentary canal. In 
scrofulosis and rickets it is, I think, inferior to the phosphates. 

Phosphate of Calcium.— The phosphate of calcium is, as is well 
known, an essential ingredient of bone, of which, indeed, according to 
the analysis of Berzelius, it forms more than fifty per cent. ( Traite de 
Chimie , Paris, 1833). It should not be forgotten, however, that it exists 
in notable quantities in all the tissues, and is probably as essential an 
ingredient of their structure as of that of bone. Whenever it is taken 


ALTERATIVES. 


549 


out of the food of animals, although they be otherwise well fed, sooner 
or later they waste, sicken, and die. Chossat fed pigeons exclusively 
on corn containing very little of the phosphate of calcium, and found 
that after some months they wasted, were affected with diarrhoea, and 
died ( Comptes-Rendus , t. xiv.). According to Roloff ( Virchow's Archiv, 
Bd. xlvi. p. 302), a herd of cows which had been fed upon hay from a 
certain meadow were very much out of health, and suffered from fra - 
gilitas ossiinn. On examination, the hay was found to be nearly free 
from earthy salts, and upon bone-meal being given to the cows they 
recovered their health in four weeks. The same authority further 
states that, in some meadows with which he is acquainted, the disease 
is endemic among the cows because the grass is so poor in phosphates. 
Haubner also affirms ( Schmidt's Jahrb., Bd. cli. p. 138) that cattle fed 
exclusively upon potatoes, or upon roots very poor in phosphates, fail 
to fatten, become weak, and are apt to suffer from caries, but that if 
the phosphate of calcium be given they rapidly improve; and E. Yoit 
( Zeitschr . /. Biologie , xvi. 198) states that rachitis without emaciation 
can be produced in three or four weeks in young dogs by taking the 
phosphate of calcium out of the food. Hegar ( Schmidt's Jahrb., Bd. cli. 
p. 138) has considered the absorption of the phosphate of calcium, when 
given as a medicine, very doubtful, because when he exhibited it freely 
there was no increase in the amount of the phosphoric acid or of the 
earthy bases in the urine. Boker (Ibid.), on the other hand, has found 
that if the drug be given to those wet-nui'ses whose milk contains an 
abnormally small amount of phosphates, the milk soon becomes rich 
in the earthy salts, and L. Perl ( Virchow's Archiv, lxxiv. 54) has found 
that administration of the phosphates is followed by an increase in 
their amount in the urine. Further, Albert Riesell (Hoppe-Seyler’s 
Aledicin.-chem. Untersuch., p. 318) has shown that the phosphates are 
eliminated by the intestines, and therefore that even if it were a con¬ 
stant fact that their renal excretion is not augmented by their admin¬ 
istration, it would not prove that they are not absorbed. M. Teissier 
has found that in the early stages of phthisis there is a very great 
increase in the excretion of the earthy phosphates by the kidney (Le 
Mouvement Med., Sept. 1875), and the researches of Professor Beneke* 
(Schmidt’s Jahrb., Bd. cli. p. 138) are said to have shown that this in¬ 
creased renal elimination, which plainly occurs in several allied diseases, 
is not accompanied by any increase in the amount ingested in the food, 
or decrease of the amount eliminated by the intestines, and that, con¬ 
sequently, there is a very decided wasting of the normal phosphates of 
the body. This being so, the use of phosphates in these diseases is as 
rational as that of iron in anaemia. 

Therapeutics. —According to Dusart (Archives Gen., 6e ser., t. xv.), 


* I have not had access to the original memoir of Beneke, Zur Wurdigung des Phosphors 
Kallcea in phyaiolog. und therapeut. Beziehung, Marburg, 1870. 



550 


GENERAL REMEDIES. 


to Beneke (loc. cit.), and to Teissier ( loc. cit.), the diseases in which the 
phosphate of calcium is especially indicated are rachitis, osteomalacia, 
phthisis, and scrofulosis. It is evident that the indications for the earthy 
salts are very strong in the first two of these atfections; and clinical 
experience has certainly borne out the results of a priori reasoning. In 
scrofulosis, the call for the drug is not so plain ; but Professor Beneke 
states that in many cases, if the urine be examined, it will be found to 
be abnormally rich in earthy phosphates, and that under these circum¬ 
stances the remedy is of the greatest value. Cases are not rare of 
children of slow development, often seemingly well nourished and ro¬ 
bust, and yet really pale and with flabby flesh, but without any distinct 
symptoms or marks of scrofulosis or of rachitis. Under these circum¬ 
stances, the child is in a condition allied to that of the diathesis spoken 
of, and of the value of the phosphate of calcium I have no doubt. In 
cases of delayed union after fracture, the present remedy is seemingly 
indicated, especially since Dusart (loc. cit.) has experimentally proved 
that when given to animals whose bones have been broken it hastens 
union and makes the callus abnormally heavy and firm. The phosphate 
of calcium has been recommended in various diseases other than those 
mentioned, but its value is much more doubtful. Bennett commends it 
in chronic phthisis; Piorry ( Journ. de Chun. Med., t. ix., 1863), in syphi¬ 
litic periostitis; Beneke, in syphilitic gummata; Schonian, and also Kugel- 
mann, in the menorrhagia of anaemic women. Professor Beneke calls 
attention to the use of it during pregnancy, and believes that it exerts 
an influence on the foetus, so that women who have borne, it may be, 
only rachitic or scrofulous children will bring forth healthy offspring. 

Administration.— The U.S. Pharmacopoeia recognizes the Precipi¬ 
tated Phosphate of Calcium (Calcii Phosphas Prcecipitatus ), a white, in¬ 
odorous, tasteless powder, which is prepared by dissolving bone-ash in 
muriatic acid and precipitating with ammonia. This may be employed 
in doses of ten grains three or four times a day, but, owing to its in¬ 
solubility, is not so useful as the so-called lado-phosphate of lime. This 
preparation, originally suggested by Dusart and Blache (Archives Gen., 
t. xv. p. 67), is made by the action of lactic acid upon the phosphate 
of calcium, and was found by those experimenters to be soluble in all 
proportions not only in water but also in the gastric juice. There is 
prepared by the druggists in this city an emulsion containing fifty per 
cent, of cod-liver oil and two grains of the lacto-phosphate of lime to 
the drachm, which has appeared to me to be the best of all the altera¬ 
tive preparations in cases of the character spoken of in the section on 
therapeutics. It certainly is very often more easily digested than the 
pure oil. The dose is a teaspoonful to a tablespoonful, or even more, 
according to the age. 

Under the name of chemical food, or compound syrup of the phos¬ 
phates, a very complex preparation has been much used in disorders 


ALTERATIVES. 


551 


attended with impaired nutrition, such as the lacto-phosphate of lime 
has been recommended in. I have had no experience with it, but very 
much doubt its being superior, or even equal, to the latter drug. 

COLCHICI SEMEN-COLCHICUM SEED. U.S. 

COLCHICI RADIX—COLCHICUM ROOT. U.S. 

Colchicum autumnale, or meadow saffron, whose products the above 
drugs are, is a little plant growing in Continental Europe and in England. 
It is not really the root that is officinal under the name of colchicum 
root, but the thickened swollen end of the stem, with the little bulblet 
whose office it is to develop a new plant. This corm is solid and fleshy, 
an inch and a half to two and a half inches in length, with a longitudinal 
groove, having a nail-like process (the bulblet) at its base. In the shops 
it is very commonly kept in transverse slices, which are notched and 
cordate ; the taste is bitter, hot, and acrid. Colchicum seeds are nearly 
round, about an eighth of an inch in diameter, and of a bitter, acrid 
taste. The active principle of both seed and corm is an alkaloid, Col¬ 
chicine, whose individuality was first made out by Geiger and Hesse. 
According to Hiibler, it is slowly soluble in water, readily so in alcohol, 
and not at all so in ether: with concentrated nitric acid it makes a violet 
solution, which when diluted with water becomes yellow; with concen¬ 
trated sulphuric acid it strikes an intense yellow. By the action of 
mineral acids and by other agencies it is resolved into a brownish-green 
insoluble resin and a crystallizable neutral substance, soluble in water, 
Colchiceine. 

Physiological Action.— When taken in dose of sufficient size, col- 
chieum acts upon man as a poison, producing repeated, uncontrollable 
vomiting, with nausea and retching, and also violent purging, at first of 
serous character; afterwards the passages become smaller, more mucous, 
with flakes in them, and finally in some cases bloody. Abdominal pain 
may be absent or present, but if present is generally griping; sometimes 
there is gastric burning. Nervous symptoms have been prominent in 
some of the severe cases. In one instance, it is said, a feeling of numb¬ 
ness or prickling was complained of by the patient; but this seems not 
to be common. Spasms are very frequent, and sometimes convulsions, 
which may be fatal, are present. Muscular pains are not rarely ex¬ 
perienced, in some cases replacing the spasms, and probably in all other 
cases coincident with them is great muscular weakness, amounting, as 
death approaches, to paralysis. Finally, a condition of collapse develops 
itself, the circulation fails more and more, the pulse, which has been 
frequent and feeble, becomes rapid and thready, the skin cold, pale, 
or livid, and bedewed with sweat, and death from exhaustion results. 
Consciousness is preserved until the last. The effect of lethal doses of 
colchicum on the urinary secretion varies: sometimes the kidneys seem 
to be nearly unaffected almost to the last; sometimes their functional 
activity is decidedly increased, but in other cases it is diminished, and 


552 


GENERAL REMEDIES. 


even suppression of urine has been noted. The symptoms produced by 
the largest therapeutic doses of colchicum are slowing of the pulse, 
nausea, vomiting, abdominal uneasiness, borborygmi, and free purging, 
together with a sense of prostration and of weakness. The occurrence 
of the inflammatory changes after the hypodermic injection of colchi¬ 
cine proves that the irritant principle of colchicum acts by absorption, 
and that the intestinal symptoms are not simply due to a local action, 
—deductions confirmed by the chemical experiments of Aschoff, who 
found colchicine in the liver, kidneys, heart, lungs, and blood of a 
rabbit poisoned with one and a half grains of it. 

Upon most animals colchicum acts very much as it does upon 
man, in poisonous doses producing, as prominent symptoms, severe and 
often bloody purging, vomiting, great prostration, embarrassed respira¬ 
tion, finally more or less pronounced paralysis, and death, not rarely 
preceded by convulsions. Reflex actions are lessened, and finally abol¬ 
ished (Albers, Rossbach), in the frog; but Rossbach affirms that there 
is a precedent stage of convulsions with excessive reflex activity; in 
warm-blooded animals this first stage of excitement is rarely, if ever, 
seen. According to the elaborate experiments of Rossbach, the motor 
nerves and the striated muscles are not affected by the poison, but the 
higher neiwe-centres, the spinal cord, and the peripheral sensory nerves 
suffer palsy. The same observer found that the circulation was very 
little influenced, that the pneumogastrics were not affected until near 
death, and that the splanchnic and intestinal vagi escaped altogether. 
In no case do reflex spinal convulsions occur at any time. 

A curious fact noticed by Schroff, which shows that colchicine really 
has little direct influence upon the nervous system, is that the rapidity 
of death is not at all in proportion to the size of the dose. Thus, in 
his experiments, the fatal result occurred in rabbits after one and a 
half grains of the alkaloid, in fourteen hours; after fifteen grains, in 
eleven hours. This fact, which has been confirmed by Rossbach 
(Pharmak . Untersuch., Bd. ii. p. 24), seems to be explicable only by the 
supposition that colchicine kills chiefly by its irritant action on the 
alimentary canal, and, not being in any dose corrosive, requires time 
io work out the fatal result, through the instrumentality of a gastro¬ 
enteritis. This deduction is confirmed by the long-protracted course of 
the poisoning after small doses. Thus, Aschoff noted death on the 
ninth day in a pigeon which had received one-fourth of a grain of the 
alkaloid. 

After death from colchicum, the blood is generally found very dark 
and imperfectly coagulable; but whether this is due to a direct action 
of the poison, or is the result of the slow death by asphyxia and ex¬ 
haustion, has not been determined. The chief changes are, however, in 
the alimentary canal, the mucous membrane of which is much swollen, 
intensely congested, sometimes ecchymotic, or with blood free in the 
intestine. 


ALTERATIVES. 


553 


Geiger ( Annal. Chem. Pharm ., vii. 274), Hoppe, Aschoff ( Viertel- 
jahresschrift fur Praht. Pharm., vi.), Schroff ( Oester. Zeitschrift f. Prakt. 
Heilk., 1856), and Albers ( Deutsche Klinik, 1856, xxxvi.) have experi¬ 
mented with colchicine , and have shown that it causes symptoms sim¬ 
ilar to those produced by colchicum,* of which it is without doubt 
the active principle. The closer studies of Schaitanoff, Rossbach, and 
Paschlcis ( Schmidt's Jahrb., cci. 232) appear to have yielded contra¬ 
dictory results. Schaitanoff and Paschkis found that the alkaloid 
notably increases the arterial pressure; Rossbach, that the circulation 
is but little affected; while in Rossbach’s experiments there was a nar¬ 
cosis which seems to have been replaced in the experiments of Pasch¬ 
kis by a peculiar loss of sensibility. The last observer noted also that 
neither the vagi nor the splanchnics were affected. All observers ap¬ 
pear to agree in statingf that the chief force of the poison is expended 
upon the alimentary canal, at least in mammals, and that after death, 
even when the alkaloid has been given hypodermically, the intestinal 
mucous membrane is found much inflamed, as is also very frequently 
the inner coat of the stomach. Paschkis has found that the normal 
excitability of intestinal peristalsis by galvanization of the pneumo- 
gastric nerve is destroyed by colchicine. 

The action of poisonous doses (one to two grains) of colchiceine has 
been studied upon dogs by Dr. Samuel R. Percy. The symptoms are 
very similar to those produced by colchicine; they are—increase in the 
frequency of the pulse, severe purging with tenesmus, vomiting, finally 
great slowing of the pulse and failure of the heart’s action, and death 
without convulsions. The urine, at first increased, was afterwards 
suppressed. On post-mortem examination, the mucous membrane of 
the intestines was found highly inflamed, that of the- stomach slightly 
so, and the heart and arteries were filled with black tarry blood, similar 
to that of colchicine-poisoning. On the other hand, Paschkis asserts 
that one and a half grains of colchiceine injected into the jugular vein 
of a dog produced no results whatever. It is evident that the two 
experimenters had different substances. 

The main interest to the therapeutist in the physiological study of 
colchicum, of course, is in regard to its action in small therapeutic 
doses. The most prominent result of the ingestion of such amounts is 
gastro-intestinal disturbance, as shown by abdominal uneasiness, colicky 
pains, borborygmi, loss of appetite, moderate purging, and sometimes 
nausea,—symptoms differing in degree only from those of poisoning by 
the drug. Before they come on, however, there is a lowering of the 
pulse-rate, sometimes as much as twelve beats per minute. Upon the 


* Dr. R. Lewins’s experiments ( Edinb. Med. and Surg. Journ., vol. Ivi., 1841) may be em¬ 
ployed for comparison. He used colchicum. 

j- Unfortunately, the works of nearly all these investigators are known to me only at 
second-hand. Not having had access to the original papers, I have been forced to depend 
upon abstracts in various journals. 



554 


GENERAL REMEDIES. 


skin the medicine occasionally acts, producing in some cases diaphoresis , 
and it is said that the amount of this action is in inverse ratio to the 
effect on the bowels. According to Schroff, the one-hundredth of a 
grain of colchicine* is rather more than the therapeutic dose, and pro¬ 
duces purging, lasting for several days, with griping pains, cerebral 
distress, a pulse at first lowered but afterwards accelerated, and a 
secretion of thick lateritious urine. Any nervous symptoms, such as 
vertigo, headache, muscular weakness, which may be present as the 
result of the administration of colchicum, are probably sympathetic 
upon the gastro-intestinal irritation. It is evident that colchicum in¬ 
fluences the bowels powerfully, and probably in this way acts as an 
eliminative. But in the minute doses often used with advantage in 
disease, purging does not occur, and consequently increased elimina¬ 
tion, if it takes place, must be through the kidneys: great interest 
therefore attaches to the influence of the remedy upon the urinary 
secretion. In considering this, the effects of poisonous and of thera¬ 
peutic doses must not be confounded, for it is very evident that an 
irritation which causes suppression of urine may, when present in a 
much milder degree, produce an increased flow. 

It seems very certain that in moderate doses, repeated at regular 
intervals, colchicum very often increases the flow of urine. In 1828, 
Chelius announced that during its administration in gout the amount 
of uric acid eliminated is nearly doubled. Dr. B. Lewins ( Edinburgh 
Medical and Surgical Journal , 1841, vol. lvi. p. 200) submitted the urine 
of several persons suffering from gout, taken before and after the ad¬ 
ministration of colchicum, to Professor Christison, who found in the 
colchicum-urine the proportion of urea nearly double, and that of uric 
acid greater! than, that of the other specimens. 

In 1852 Dr. Maelagan ( Edinburgh Journ. Med. Sci ., 3d series, vol. 
xiv. p. 24) analyzed the urine of three cases of rheumatism before and 
after the exhibition of colchicum: in two instances the proportion of 


* Drs. Mairet and Combemale ( Comptes-Rendus , civ. 515) have made a series of experi¬ 
ments to determine the dose of colchicine. They find that if given by the stomach it causes 
when in the dose of 0.0002 gramme per kilogramme in the lower animals no diarrhoea, but poly¬ 
uria; of 0.00025 gramme per kilogramme, violent purgation, with a little general depression; 
of 0.000476 gramme per kilogramme, violent bloody diarrhoea, with salivation, polyuria and 
great feebleness, lessening of the temperature, and rapid respiration. Given hypodermically, 
the diuretic dose is 0.00015 gramme, the purgative dose 0.00025 gramme, and the toxic dose 
0.00035 gramme, per kilogramme. When given to the healthy man by the mouth it produces 
in doses of 0.0002 to 0.003 gramme mild headache, muscular weakness, abdominal pains, 
increased frequency of the pulse, thirst, increased diuresis; in doses of 0.005 gramme, diar¬ 
rhoea and diminution of the urine. In experiments upon two gouty individuals under the in¬ 
fluence of a purgative dose of colchicine (0.0005 gramme) the urine was lessened in quantity, 
as was also the elimination of urea, but the elimination of uric acid was distinctly increased. 

f Dr. Harley {The Urine and its Derangements, Phila., 1872, p. 81) makes the assertion 
that colchicum diminishes the excretion of uric acid and even the urea: as, however, he does 
not deem it necessary to give any authority for the assertion, and as he does not appear to 
have made any elaborate chemical examination himself, not much weight is to be attached to 
his testimony. 



ALTERATIVES. 


555 


urea was very greatly increased, that of uric acid slightly so. In the 
third case the effect just noted happened at first, but not afterwards. 

On the other hand, Professor Stille states that Graves and Gardner 
affirm that the urates diminish under the use of the medicine. It is evi¬ 
dent that these different results are not so contradictory as they seem, 
for it is possible that in one case the colchicum may so act as to increase 
the elimination of urea, in another that of uric acid, and that when one 
of these is increased the other may be unaffected, or even diminished. 

Further, when the medicine purges freely it is very probable that 
elimination by the kidneys is lessened; and no account of this is taken 
by any of the observers whose original papers I have seen. Moreover, 
these observers also all contented themselves with noting the propor¬ 
tion of urea and ui'ic acid in the urine, when it is evident that the 
mere proportion, unchecked by the absolute amount of urine secreted 
during the twenty-four hours, is no criterion as to the absolute amount 
eliminated. Dr. A. B. Garrod {Med.- Chir. Trans ., 1858, xli. 348) has 
made a study of the subject in such a way as to avoid this fallacy, and 
found that in some cases the amount of urea and uric acid eliminated 
was seemingly lessened, while in others it was seemingly increased; on 
the whole, no marked effect was produced. More precise and extended 
investigations are still needed to settle the question, but there is cer¬ 
tainly at present no proof that colchicum in gout materially influences 
elimination. 

The action of the drug upon the urine during health is evidently 
very closely connected with the question just discussed. Here again 
we find conflicting and insufficient testimony. Dr. Bird ( Urinary De¬ 
posits , Phila., 1859, p. 354) quotes Professor Kramer’s* experiments as 
showing that colchicum does not increase the amount of solids elimi¬ 
nated, and intimates that his own investigations had given similar 
results. Dr. Hammond {Proc. Phil. Acad. Nat. Sci., Dec. 1858), on the 
other hand, in a series of experiments in which every care to avoid 
fallacies, by maintaining equality as to diet and exercise, was observed, 
found that while squill and digitalis only increased the watery part of 
the urine, both the organic and the inorganic solids were remarkably 
increased by colchicum. 

In regard to colchiceine , the experiments of Professor S. B. Percy 
{Amer. Med. Times , April, 1862, p. 167) indicate, but are much too few 
to prove, that in gout it increases the elimination of urea and uric acid. 

Therapeutics. —Our knowledge of the use of colchicum in disease 
is purely empirical, based upon clinical experience; and our acquaint¬ 
ance with its physiological action is not sufficient to enable us even to 
explain fully what experience has taught, much less to guide us in our 
use of the drug. Gout is the one disease in which colchicum is almost 
universally recognized as a specific. It may be advantageously em- 


* Kramer’s paper was published in Keller’s Archives, Dec. 1847, and is inaccessible to me. 



556 


GENERAL REMEDIES 


ployed both as a preventive of the paroxysm and to lessen its severity 
when developed. During an attack of gout, from ten to twenty drops 
of the wine of colchicum root may be exhibited every four hours until 
some decided evidence of its action, such as nausea or slight purging, 
is induced. It should always be borne in mind that although looseness 
of the bowels may be useful, yet when colchicum purges the gouty 
patient actively it mostly fails in achieving the desired therapeutic 
result. Its action is most favorable when its influence is felt chiefly 
upon the skin and the kidneys. To effect this desired result, it is often 
well to restrain the tendency of the drug to act upon the bowels, by 
combining it with opium. This is especially the case in debilitated 
subjects, in whom anything like over-purgation must be avoided with 
the most scrupulous care. By large purgative doses of colchicum the 
paroxysm of gout may often be suppressed; but experience has shown 
that this use of colchicum is dangerous, the suppression being some¬ 
times followed by serious internal disease, apparently due to a transfer 
of the gouty irritation. Between the paroxysms, colchicum may be 
steadily exhibited to the gouty subject in small doses (ten drops of the 
wine of the root three times a day); and often great advantage is 
derived from its combination with iodide of potassium. This com¬ 
bination is especially useful in irregular atonic gout, such as is most 
frequently seen in women of feeble nervous organization who have 
inherited the diathesis, but is sometimes present even in robust men. 
Ten grains of the iodide and ten drops of the colchicum wine may be 
given three times a day. Speculations as to how colchicum cures gout 
appear to me useless in the present state of our knowledge: until we 
know more of the physiological action of the drug and of the nature 
of the disease, one theory seems as good as another. 

In rheumatism , colchicum has been highly recommended by some, 
but has never come into such general use as in gout. In the inflamma¬ 
tory variety of the disease it is of but little value, except in purgative 
doses, and is mostly administered in the form of Scudamore's Mixture, 
which is composed of magnesia and its sulphate with wine of colchi¬ 
cum root. In subacute rheumatism , the combination of colchicum and 
iodide of potassium, already spoken of, is very useful. 

Colchicum has been administered in various diseases, but when there 
is no rheumatic or gouty taint is at present very rarely used. 

Toxicology.— The symptoms of poisoning by colchicum have been 
already enumerated. The fatal dose varies, but is small. Professor 
Geo. B. Wood ( U.S. Dispensatory , 13th ed., p. 1504) states that death 
has been produced by two drachms and a half of the wine of colchicum 
root; and Taylor ( Medical Jurisprudence , 2d ed., vol. i.) records a case 
in which three drachms and a half pi’oved fatal. On the other hand, 
recovery has taken place after the ingestion of an ounce.* According 


* See case in L' Union Medicale, Aug. 1848. 



ALTERATIVES. 


557 


to the experiments of Schroff, colchicine is eighty to one hundred times 
stronger than the fresh corm. According to Heinrich,* 0.15 grain of 
colchicine will produce poisonous symptoms in man, and in Krahmer’s 
experiments ( Journal fur Pharmakodynamik, ii. 561) 0.3 grain caused 
in an adult violent serous purging, lasting for four days, and accom¬ 
panied with severe tenesmus. Casper has seen death result from a 
quantity of the wine containing 0.025 to 0.03 gramme (0.37 to 0.45 
grain) of colchicine; but, according to Husemann, recovery has taken 
place after the ingestion of 0.045 gramme of the alkaloid. Dr. Geo. 
W. Major ( Canada Med. and Surg. Journ ., Dec. 1873) records seven¬ 
teen cases of poisoning from one bottle of wine of colchicum seeds 
occurring in Montreal, seven of which proved fatal. The patients had 
been vomiting and purging almost continuously for many hours when 
first seen, and the symptoms were exactly those of the stage of col¬ 
lapse of severe cholera morbus. In no case was the purging bloody. 
Consciousness was preserved to the last, and in only one case was 
there anything like convulsions. There was decided numbness of the 
extremities; and a peculiar hoarseness of the voice was especially 
noted. 

The treatment of colchicum-poisoning is as follows. If the stomach 
and bowels have not been freely evacuated, administer at once an 
emetic and a cathartic, so as to empty the alimentary canal; allow the 
patient to drink freely of warm water, to aid in these operations and 
to act on the kidneys. Give freely of tannic acid, as the only known 
chemical antidote; although experiments upon animals have shown 
that it is not to be relied upon. To check the vomiting and purging, 
administer opium freely; and to allay the irritation, cause the patient 
to drink freely of albuminous matter, such as white of egg dissolved 
in water: the tannic acid having been given as soon as possible after 
the taking of the poison, the demulcents are useful in the more ad¬ 
vanced stages. Symptoms of gastro-enteritis or of collapse are to bo 
met as they arise. 

Administration. —Colchicum is never used in substance; the wine 
of the root is deservedly the most popular preparation. It has been 
asserted that colchicine hypodermically administered is especially effi¬ 
cacious in rheumatism; the dose is one-fiftieth of a grain ( Berl. Klin . 
Wochenschr ., 1877, 197). 

The officinal preparations from the seeds are: the tincture ( Tinctura 
Colchici Seminis —1 to 6.6), dose, half a teaspoonful to one and a half 
teaspoonfuls; the wine ( Vinum Colchici Seminis —1 to 6.6), dose, half a 
teaspoonful to one and a half teaspoonfuls; and the fluid extract {Fx- 
tractum Colchici Seminis Fluidum), dose, two to six minims. 

The officinal preparations of the root are: the wine ( Vinum Colchici 
Radicis —1 to 2.5), dose, ten to fifteen drops; as a purgative, half a 


* Quoted by Husemann. 




558 


GENERAL REMEDIES. 


fluidrachm; the extract (Extractum Colchici Radicis ), dose, one to two 
grains; and the fluid extract (Extractum Colchici Radicis Fluidum), 
dose, two to four minims. 

SARSAPARILLA—SARSAPARILLA. U.S. 

The root of Smilax officinalis and other species of Smilax, woody 
vines inhabiting Mexico and the northern portions of South America. 
There are in commerce a number of varieties of sarsaparilla, the two 
most important of which are the Honduras and the Brazilian. The 
former of these is almost the only sarsaparilla used in this country. It 
occurs in bundles two or three feet long, composed of several very long, 
thin roots, folded upon themselves, the whole being bound round by a 
number of turns of the root. The Brazilian sarsaparilla also comes 
in cylindrical bundles, each of which is closely wrapped about by a 
very flexible stem: it mostly has fewer rootlets than the Honduras 
variety. The crude sarsaparilla has little or no smell, but its taste^ 
which is at first simply mucilaginous, soon becomes, if the root be 
chewed, persistently acrid. According to Professor Geo. B. Wood, the 
degree of this acridity is the best measure there is of the activity of 
any specimen of the drug. Sarsaparilla contains a crystallizable prin¬ 
ciple, first discovered by Palotta in 1824. From its discoverer this 
substance received the name of Paraglin. By subsequent authorities it 
has been variously called Smilacin , Salseparin, Sarsaparillin, and Paral- 
linic Acid. Paraglin, according to Poggiale, crystallizes in fine needles. 
according to Thubeuf, in star-like clusters of plates. It has a neutral 
reaction, and in solution a bitter, acrid taste, but when solid it is nearly 
tasteless. It is very slightly soluble in cold water, more so in boiling 
water; moderately soluble in dilute alcohol when cold, freely so when 
hot. Palotta asserts that thirteen grains of it cause vomiting, con¬ 
striction in the throat, weakness, diaphoresis, and depression of the 
circulation. On the other hand, Bdcker, of Bonn, has exhibited it in 
doses of a like amount without producing any symptoms whatever 
(Journ. fur Pharmakodynamik , Bd. ii. p. 23). 

Physiological Action. —It has already been shown that there is 
very little reason for believing that paraglin has much immediate action 
on the system; and the question naturally arises, Has sarsaparilla any 
more influence? The answer to this question must, I believe, be a 
negative one, since the only sensible effects that follow even the largest 
draughts of the decoction are simply the results of slight gastric dis¬ 
turbance. It has been asserted that sarsaparilla acts as a diuretic and 
diaphoretic; but the only record I have met with of any careful ex¬ 
perimentation is that of Bocker (loc. cit.). That investigation seems to 
show conclusively that the drug has no marked influence upon these 
secretions. If, therefore, sarsaparilla have any value whatever in dis¬ 
ease, it must be simply as an alterative,—as a remedy which in some 
unknown way modifies nutrition. 


ALTERATIVES. 


559 


Therapeutics. —Sarsaparilla has been used, and still is used, to such 
an enormous extent in medicine that it seems impossible to believe that 
it is destitute of therapeutic virtue. It is not in accordance with the 
plan of the present work to enter into an elaborate discussion of the 
recorded clinical experience with it: suffice it to say that, although the 
evidence is contradictory, on the whole there is a decided preponder¬ 
ance in favor of the value of the drug in chronic syphilis and in chronic 
scrofulous diseases. I have used it largely, but always in combination 
with more powerful alteratives, so that it is impossible to decide how 
much of the good achieved has been due to its influence. There are 
two distinct methods or objects of the use of sarsaparilla in syphilis: 
one as an adjuvant to mercury in the secondary stage; the other as an 
adjuvant to the iodide of potassium, or as a sole reliance, in the advanced 
tertiary cases, especially where the constitution is very much broken 
down by the disease. It is stated that, in the latter condition, ver} r 
often during its use the appetite will gi'adually increase, the spirits 
rise, the secretions become more and more normal, and the strength 
grow day by day. 

Administration.— Sarsaparilla is never given in substance, but in 
one of the following officinal preparations: 

Decoctum Sarsaparilla; Compositum—Compound Decoction of Sarsa¬ 
parilla .—This contains sarsaparilla, bark of sassafras root, guaiac wood, 
liquorice root, and mezcreon, and is an imitation of the famous u Lisbon 
Diet-Drink." The dose is three or four fluidounces three or four times 
a day. 

Syrupus Sarsaparillce Compositus—Compound Syrup of Sarsaparilla. 
—This contains sarsaparilla, guaiac wood, pale rose, senna, liquorice 
root, oil of sassafras, oil of anise, and oil of gaultheria, and is a very 
popular preparation, on account of its pleasant taste: it affords the 
only vehicle I know of capable of disguising the taste of the iodide of 
potassium. The dose of it is one to two tablespoonfuls three or four 
times a day. 

Extractum Sarsaparillce Fluidum—Fluid Extract of Sarsaparilla .— 
Dose, half a teaspoonful three times a day. 

Extractum Sarsaparillce Compositum Fluidum—Compound Fluid Ex¬ 
tract of Sarsaparilla .—This contains sarsaparilla, liquorice root, sassafras, 
and mezereon. The dose is a teaspoonful. 

GUAIACI LIGNUM—GUAIAC WOOD. U.S. 

GUAIACI RESINA—GUAIAC RESIN. U.S. 

The wood and the resin of Guaiacum officinale, a large tree grow¬ 
ing in the West Indies. Guaiac wood, or lignum-vitce, is imported in 
billets, but very generally is kept in the shops in the form of rasp¬ 
ings or shavings. It is a very dense wood, the central heart-wood 
having a dark-olive or brownish-green, and the outer sap-wood a light- 
yellowish, color. It is inodorous, but becomes somewhat fragrant when 


560 


GENERAL REMEDIES. 


rubbed or heated. Besides the resin, it contains an extract which is 
believed to have medicinal properties. 

Guaiac resin is obtained to a slight extent by spontaneous exudation 
from the living trees; much more largely by boring a hole into the 
centre of one end of a billet, placing the other end in the fire, and 
catching the melted resin as it runs out; and still more frequently by 
boiling the chipped wood in salt and water and skimming off the resin 
as it rises to the surface. Guaiac occurs in irregular lumps or masses, 
of a dark reddish-brown greenish color externally, offering a conchoidal 
fracture with somewhat translucent edges. The odor is feeble, peculiar, 
agreeable, increased by heat. The taste is at first very slight, but, as 
the resin melts in the mouth, it becomes very acrid and persistent. It 
is an exceedingly complex body, containing three acids, the guaiaconic 
acid of Hadelich, the guaiac acid of Righini, and the guaiacresinic 
acid of Hlasiwetz, besides guaiac yellow , a peculiar resin, and other sub¬ 
stances. Landerer asserts that he has found in it a peculiar crystal- 
lizable substance, which he calls guaiacin (Husemann, Die Pflanzenstoffe, 
p. 1106.) 

When a lump of guaiac is freshly broken, it offers a dark, blackish 
surface, which on scraping or bruising becomes yellowish ; on exposure, 
the well-known greenish tint is acquired, owing to a spontaneous oxi¬ 
dation. The ease with which the resin undergoes oxidation is its most 
distinctive characteristic. As already stated, the change occurs on 
simple exposure to the light. According to Wollaston, it is most rapid 
and perfect in the focus of the violet rays of the spectrum, while in 
the focus of the red rays the original color is regained. Oxidizing or 
ozonizing agents, such as nitric acid, chromic acid, iodine, bromine, and 
chlorine, produce this oxidation very rapidly and very thoroughly, the 
resin acquiring an intense blue color. 

Physiological Action. —Guaiac is believed by some to act as a dia¬ 
phoretic, and to do good by increasing the elimination of the skin ; but, 
as I have not been able to obtain either from medical literature or from 
the exhibition of the medicine any distinctive proof of its having such 
action to any marked extent, I have preferred to consider the drug as 
an alterative. When taken internally, very little sensible effect results, 
unless the dose be so large as to irritate the stomach. 

Therapeutics.— Guaiac has been very largely employed in chronic 
syphilis, in connection with sarsaparilla, and is an ingredient of its 
most favorite preparations. It has also had a good deal of repute in 
rheumatism , and in the subacute and chronic forms of the affection is 
often of service. For an account of its employment as an emmena- 
gogue, see the chapter upon that class of remedies. Guaiac is best 
administered in tincture, either the simple ( Tinctura Guaiaci , U.S.) or 
the ammoniated ( Tinctura Guaiaci Ammoniata, U.S.). The dose of 
either of these is from one to two teaspoonfuls, administered, prefer¬ 
ably in milk, three or four times a day. 


ALTERATIVES. 


561 


Mezereum. — Mezereon is the bark of two species of Daphne, native 
shrnbs of Europe. It is a thin, grayish, tough, flexible bark, occurring 
in long strips folded upon themselves, nearly odorless, but having a 
very acrid taste. It contains a neutral, crystallizable, bitter glucosidc, 
Daphnin, besides a volatile acrid principle. Mezereon is intensely irri¬ 
tant, and its ointment ( Unguentum Mezerei, U.S.) is used as a stimulant 
dressing to very indolent ulcers, and to keep blisters sore or to maintain 
issues. Internally, in small doses it is believed to be an alterative, but 
is never used except in combination with sarsaparilla. In overdoses it 
is an active poison, producing severe vomiting, purging, and gastro¬ 
intestinal inflammation. Sometimes the symptoms of the poisoning 
are simply those of collapse, with unconsciousness and other nervous 
disturbances, such as are seen in children from intense gastro-intestinal 
irritation (case, Brit. Med. Journ ., 1882, vol. ii. p. 521). 

Sassafras. —The bark of the root of Sassafras officinale is believed 
by some to be an alterative, on, as I think, very slight foundation. 
It contains some tannic acid, and very largely of a volatile oil ( Oleum 
Sassafras ), which, on account of its cheapness and its agreeable odor 
and taste, is much used both in medicine and in the arts as a flavor 
and perfume. 

Taraxacum. U.S.—The root of the common dandelion, Taraxacum 
officinale, is believed to have the property of altering the action of the 
liver; although no effect is to be witnessed from a single dose of the 
drug, however large, other, at least, than some nausea. Diuretic prop¬ 
erties have also been ascribed to taraxacum : but the only evidence 
brought forward to establish this is the vulgar name which the plant 
bears both in English and in French. If useful at all, it is in those cases 
of dyspepsia in which there is habitual torpor of the liver, with costive¬ 
ness. It must be given very freely and continuously for weeks before 
any good effect is to be looked for. The U.S. Pharmacopoeia recognizes 
a fresh juice extract (Extradum Taraxaci ) and a fluid extract (Extraction 
Taraxaci Fluidum), either of which may be used in doses of one or two 
drachms, administered after meals. 

ICHTHYOL. 

Ichthyol is a substance first prepared by Schroeter by the distilla¬ 
tion of a peculiar bituminous sulphurous mineral obtained from the 
deposits of fossil fish. It occurs in commerce in the form of the ichthyo- 
sulphate of sodium and ichthyo-sulphate of ammonium. The ammonium 
ichthyol is a red-brown, clear, thick liquid, of a hot bituminous taste 
and smell, at a high heat burning without ash, making with water a 
clear, reddish-brown solution of a weak acid reaction, which, when 
treated with hydrochloric acid, yields a dark resinous precipitate. So¬ 
dium ichthyol is a dark, tar-like substance of an alkaline reaction, per¬ 
fectly soluble in water. Both these preparations combine- with fat and 
vaseline in all proportions. The ichthyol preparations are very rich in 

36 


562 


GENERAL REMEDIES. 


sulphur, containing, it is said, ten per cent. According to Baumann, 
they yield themselves so readily to oxygen that they are powerful re¬ 
ducing agents. 

Therapeutics. —According to Baumann and Schotten, ichthyol has 
little apparent action on the general system, and when given in doses 
of five drachms to dogs produces no symptoms save diarrhcea. As a 
local remedy it has been extravagantly praised by Unna, Kiesner, 
and a large number of German dermatologists and surgeons, and has 
also received strong encomiums in America. When applied freely in a 
pure form to the sound skin it produces slight irritation and burning. 
It is asserted to have, when used as a local application, peculiar altera¬ 
tive properties, and also the power of penetrating through the skin 
so as to be able to act as an alterative anodyne and discutient, in dis¬ 
eases not only of the skin but also of the subjacent tissues. The cases in 
which value is attributed to it are characterized generally by inflamma¬ 
tory enlargement or inflammatory pain. 

In vai’ious skin-diseases ichthyol has been used with alleged remark¬ 
able results, in chronic eczema , chronic urticaria, acne, intertrigo, lupus, 
keloid, etc. In lepra Unna combines its internal and external use (dose, 
15 grains a day). It has also been recommended in the strongest terms 
for the relief of various ulcerations of the skin and for the prevention 
of pitting in smallpox, and also in erysipelas. In lumbago and other 
forms of muscular rheumatism, in rheumatic or gouty joint-disease, indeed, 
in almost every form of subacute or chronic gout, according to Schwe¬ 
ninger, Lorenz, and others, a few rubbings with pure ichthyol or a fifty- 
per-cent. ointment will produce an immediate and remarkable effect. 
It has been largely used in the treatment of sprains, contusions, burns, 
and frost-bites. If one-half that has been said of it be true, it is a 
remedy of extraordinary power and value. Schmidt has even seen it 
soften and disperse a lipoma, and D. Hayes Agnew commends it very 
highly in the treatment of recent lymphatic enlargements. I have used 
it in sprains with apparently some relief. When the skin is intact and 
not irritated, the ichthyol itself or a fifty-per-cent, ointment may be 
employed. In erysipelas Yon Nussbaum covers the affected part, after 
thorough disinfection, with a thick layer of equal parts of ichthyol and 
vaseline, and this in turn with a thick layer of salicylated cotton. The 
result is said to be immediate, the disease disappearing in a single day. 
In various skin-diseases and ulcerations the strength of the application 
may vary from one to fifty per cent. Lorenz affirms that in acute 
coryza and inflammations of the nose or mouth a mixture of one to ten 
per cent, of ichthyol and vaseline is very efficacious. Both Unna and 
Lorenz deny that it has any antiseptic properties. 


FAMILY rV.-ANTIPERIODICS. 


CINCHONA. U.S. 

Under the general term of Cinchona, the United States Pharma¬ 
copoeia recognizes the “ bark of all the species of the genus Cinchona 
containing at least two per cent, of the alkaloids which yield crystal- 
lizable salts.” Under the name of Cinchona Flava, or Yellow Cin¬ 
chona (syn. Calisaya Bark), the same standard list includes the bark 
of Cinchona Calisaya; under the name of Cinchona Pallida, Pale 
Cinchona, that of Cinchona Condaminea and C. micrantha; under the 
title of Cinchona Rubra, Red Cinchona, that of C. succirubra. 

All the trees yielding quinine and its congeneric alkaloids belong to 
the genus Cinchona, and inhabit the slopes of the Andes Mountains 
from the northern extremity of South America to the lower portion of 
the republic of Bolivia, at an altitude of from five to ten thousand feet. 
The bark is collected by persons known as cascarilleros, and is exported 
in large bundles or bales, usually surrounded with raw ox-hide. To 
these packages the term seroons is applied. 

The Pale Bark occurs in quills or cylindrical rolled pieces, -with a 
grayish or brownish adherent epidermis. It derives its name from the 
light fawn-color of its powder. 

The Calisaya or Royal Yellow Bark comes both in quills and in flat 
pieces. The epidermis is absent, or, if present, is loosely attached. The 
powder is of a decidedly yellow color, sometimes almost orange. The 
fracture is short and fibrous, presenting semi-transparent, sharp spiculie, 
which are apt to become detached and penetrate the fingers. 

The Cinchona Rubra , or Red Cinchona , occurs in quills and in flat pieces. 
The epidermis is generally present, and is often very warty. The color 
of the powder is a faint reddish brown. Beneath the epidermis is in 
most specimens a distinct, red, resinous layer, which is very ajiparent 
in cross-section. 

Large quantities of bark under the name of Carthagena Bark find 
their way into commerce through the northern ports of South America. 
For descriptions of these the reader is referred to works on Materia 
Medica. 

Very successful attempts have been made to cultivate cinchona, 
especially in the Himalaya Mountains, Java, and Jamaica, where many 

563 . 



564 


GENERAL REMEDIES. 


millions of the trees have been planted and are thriving. The East 
India bark is already arriving in London in considerable quantities, 
and in a few years the supply from this source will doubtless be very 
large. 

Chemical Constitution. —Besides tannic, kinic, and kinovic acids, 
and other important substances, the cinchona barks contain quinine and 
quinidine, cinchonine and cinchonidine. Out of these alkaloids quini- 
cine and cinchonicine are readily formed artificially, but, so far as is 
known, they do not exist in nature. There are therefore two isomeric 
alkaloidal groups: quinine, quinidine, quinicine; cinchonine, cinchoni¬ 
dine, cinchonicine. 

QUININA. U.S. 

This alkaloid was first distinctly separated from the other ingre¬ 
dients of the bark by Pelletier and Caventou in 1820. When quinine is 
precipitated by an alkali from a solution of its salt, it usually falls as a 
hydrate, which may be crystalline. By sufficient heat the hydrate is 
melted and the water is driven off. On cooling, the alkaloid, now free 
from water, forms a white, opaque, crystalline mass. 

The neutral, officinal sulphate of quinine (Quinince Sulphas , U.S.) 
occurs in light silky crystals, soluble in seven hundred and forty parts 
of cold or in thirty of boiling water, readily soluble in alcohol, very 
freely so in acidulated solutions, nearty insoluble in ether. The aqueous 
solution, upon the addition of chlorine, and afterwards of ammonia, 
assumes a green color. According to Dr. Gr. Kerner, if the original 
solution be colorless and clear and in a clean test-tube, one-thirty- 
thousandth part of the alkaloid can be recognized by this chlorine- 
ammonia test. When to one hundred parts of the salt, dissolved in 
nineteen hundred and twenty parts of cold dilute acetic acid (sp. gr. 
1.042), are added successively four hundred and eighty parts of alcohol 
(sp. gr. 0.837) and sixty parts of a saturated alcoholic solution of 
iodine, crystals of Herapathite separate, in the form of right-angled 
quadrate rhombic leaves, which when seen by transmitted light are 
olive-green, but in reflected light are bright metallic green, resembling 
the elytra of Spanish flies. When heated, the sulphate of quinine 
becomes phosphorescent, emitting a pale-green light at 155° to 160° C., 
and at a higher temperature melts, with the development of purplish 
vapors. When the neutral sulphate of quinine is dissolved in water 
acidulated with sulphuric acid, it is converted into the soluble bisul¬ 
phate, which may be obtained in orthorhombic prisms by evaporation. 

Physiological Action.— Quinine or its salts in powder or solution 
are, when applied upon a part denuded of its epidermis, very active 
irritants. Upon the skin they have little or no influence, but upon the 
mucous membranes they exert a very perceptible stimulant or irritant 
action. 

A. Eulenburg found that when quinine was brought into contact 
with a nerve it did not cause contraction in the tributary muscles, but 


ANTIPERIODICS. 


565 


when placed upon the muscles themselves it induced immediate violent 
action. lie therefore concludes that it is not a nerve-irritant, but a 
muscle-irritant. When it is administered to dogs in sufficient quantity, 
it produces restlessness, followed by muscular tremblings, which have 
been compared to those of paralysis agitans, loss of power deepening 
into more or less complete paralysis, great dyspnoea, and cerebral symp¬ 
toms, such as anaesthesia, blindness, stupor, or violent delirium, dilated 
pupils, coma, and convulsions. When the drug is introduced by the 
stomach, vomiting generally occurs, and at times diarrhoea also.* Death 
has been shown by Heubach to be produced, at least in the lower ani¬ 
mals, by a failure of the respiration.-}- 

The first symptoms of c-inchonism, as produced by small therapeutic 
doses (ten grains) in man, are usually ringing in the ears, slight fulness 
in the head, and perhaps some deafness. With the use of larger doses 
these symptoms are intensified : the deafness is very marked, disturbed 
vision | may exist, and the flushed face, with the sense of distention in 
the head, may point towards a cerebral congestion, which is in some 
cases relieved by spontaneous epistaxis. In decided cinchonism, giddi¬ 
ness and staggering in walking are very common. After toxic doses, 
severe headache, delirium, stupor, complete deafness. and blindness, 
dilated pupils, embarrassment of respiration, great weakness, convul¬ 
sions, paralysis, and finally collapse, may result, either comatose or 
delirious. The deafness produced by large doses of quinine usually 
passes off rapidly; very rarely is there a permanent impairment of 
hearing. Amaurosis, with a peculiar retinal ischsemia, has been pro¬ 
duced by very large therapeutic doses of the alkaloid ( Archives of Oph¬ 
thalmology , x.; for a case in which sight began to return in twenty-one 
days, see Brit. Med. Journ., 1886, i. 823). 

The minimum fatal dose of quinine is not known, but it must be 
large, and probably varies very much. Dr. Clapton details (. Medical 
Times and Gazette , April, 1864) a case in which a soldier took at one 
dose an ounce of the sulphate, stirred up in some water, without the 
induction of any more serious symptom than a mild stupor; a similar 
case is mentioned by Dr. Lente, on the authority of Dr. Woodhull; and 
a third is recorded by Taussig (Stille’s Therapeutics , vol. i. p. 507). Dr. 


* See F. M. Melier, Memoires de I’Acadimie, t. xii. p. 722, 1843 ; Wm. 0. Baldwin, 
Amer. Jour. Med. Set., April, 1847; P. Briquet, Traite the rap. de Quinquina, Paris, 1855. 

f The present is perhaps as suitable a place as any to notice certain researches upon 
the relations of alkaloids to protoplasm. The relation between medicinal substances and the 
tissues upon which they act is certainly a very close one, and very probably is chemical in its 
nature. Dr. Rossbach ( Pharm. Untersuch., Bd. i., Hft. iii.) found that various alkaloids 
sensibly modify the properties of albumen, and believes that they form a chemical compound 
with it. Under the influence of the poison the albumen coagulates at a much lower tempera¬ 
ture, and is deprived of its affinity for ozone. The alkaloids also precipitate the albumen 
from its ozonized solution. 

J I have seen complete temporary amaurosis produced in a lady by twelve grains of 
quinine. 



56G 


GENERAL REMEDIES. 


B. G. Wharton records ( Amer. Journ. Med. Sci., April, 1844) a case in 
which during thirty-six hours a half-ounce was taken without vomiting 
and without ill effect. I cannot help suspecting that in all of these 
cases much of the drug passed through the intestines without absorp¬ 
tion. In the famous case of Bazire, five ounces taken in the course 
of ten days caused death. Fatal instances of poisoning by quinine 
are very rare in literature, but Husemann ( Therap. Monat ., Jan. 1888) 
has made a collection of cases in which death has been attributed 
to the alkaloid,—not always, in my opinion, with correctness. Yon 
Graefe asserts that he has seen two cases of amaurosis caused by 
quinine ; the sufferer in one instance taking half-drachm doses until six 
drachms were ingested, in the other case an ounce altogether of the 
drug. 

A close physiological study of quinine can best be made by investi¬ 
gating its effects upon the different systems of organs seriatim; and 
this shall now be done. 

Cerebrum .—According to the experiments of Briquet, a solution of 
sulphate of quinine injected into the carotid will in some cases produce 
meningitis. In doing this, it is evident, the salt acts rather as an irri¬ 
tant to the membranes of the brain than as a nervous stimulant: in¬ 
deed, experimental evidence proving that quinine is a cerebral stimu¬ 
lant seems to me to be wanting. The chief proof that the alkaloid 
does act as a stimulant lies in the fact that persons who have been 
taking it regularly for some time will occasionally, upon the sudden 
withdrawal of their daily dose, manifestly be less active without than 
with it. Briquet may be right in his belief that in small doses it acts 
as a nervous stimulant, but the proof of his correctness at present is 
clinical rather than experimental. When given in toxic doses to the 
lower animals, probably all of the cinchona alkaloids produce epilepti¬ 
form attacks. Dr. J. Jakoubowich ( Revue des Sciences Med., 1873) has 
noticed such effect with quinine in dogs, and it has been produced with 
cinchonidine in various animals. Chirone and Curci found that in the 
pigeon this action of cinchonidine is prevented by ablation of the cere¬ 
bral hemispheres, but Professor Albertoni objects with much force that 
these observers gave the pigeon the alkaloid too soon after the ablation, 
while it was still profoundly affected by the shock and hemorrhage of 
the operation (Arch. f. Exper. Path. u. Therap., xv. 278). Professor 
Albertoni found that, if the pigeon was allowed to recover, the cincho¬ 
nidine was capable of causing convulsions; also that in dogs with the 
motor zone of the cerebral cortex destroyed, the alkaloid caused epilep¬ 
tiform attacks, and that therapeutic doses do not increase the excita¬ 
bility of the cerebral cortex in the dog. The subject is one of great 
interest in connection with the circumstance, noted for quinine by 
Brown-Sequard and confirmed by Albertoni as regards cinchonidine, 
that in epileptics the attacks are rendered decidedly more frequent 
by the cinchona alkaloids. The present evidence indicates that this 


ANTIPERIODICS. 


567 


increase is not due to an influence upon the cerebral cortex, but can 
hardly be considered sufficient to be conclusive. In very large doses 
quinine without doubt abolishes the functions of the cerebrum. Louis 
Dupuis (L' Action physiol, de Quinine , Paris, 1877) found that reflex 
action was normal in poisoned dogs and rabbits, although there was 
complete loss of sensibility, and he naturally concludes that the latter 
was of cerebral origin. The disorders of special sense produced by 
quinine seem to be the result of a direct or indirect congestive action 
upon the peripheral sense organs; since Dr. Kirchner ( Sitzungsberichte 
Phys.-Med. Gesells. Wurzburg, 1881, 161) found, in rabbits, cats, and 
guinea-pigs which had been poisoned with quinine or with salicylic 
acid, very great congestion of the internal ear and of the labyrinth, 
with bloody exudation, and with, in some cases, the ear-drum swollen 
into a bladder-like body by serous exudation. These observations of 
Kirchner are very interesting, as throwing light upon the cause of the 
tinnitus aurium and deafness of cinchonism; they are in close accord 
with the observations of Dr. Roosa {Amer. Journ. Med. Sci., 1874), that 
sufficient doses of the alkaloid cause congestion of the blood-vessels 
of the middle ear, and also with an observation of my own in a per¬ 
son who suffered with chronic inflammation of the middle ear of one 
side, and in whom a dose of quinine not too large would produce 
tinnitus aurium of that side, without affecting the sound ear. 

Spinal Nerves and Centres. —Schlockow was the first to notice a £tage 
of increased reflex activity produced in the frog by quinine: its exist¬ 
ence was subsequently denied b}^ A. Eulenburg ( Reichert's Archiv, 1865), 
but has been reaffirmed by H. Heubach (Centralbl. f. Med. Wissensch., 
1874, 674) and my pupil, David Cerna, who agree in finding that it 
occurs only after very minute doses. In his investigations made in tho 
Laboratory of the University of Pennsjdvania, Dr. Cerna found that 
this stage of excitement is probably caused by a stimulant influence 
upon the peripheral sensory nerves, as it did not occur when the ab¬ 
dominal aorta was tied previous to the exhibition of the alkaloid ( Phila. 
Med. Times , x. 493). Two facts, first pointed out by Dr. T. A. Chaperon 
(, Pfluger's Archiv, 1869, 295), have been so abundantly substantiated that 
we must accept them as established. They are—in small doses quinine 
causes in the frog a lessening of the reflex activity, which is removed 
by section of the medulla, but in large doses it produces a permanent 
palsy of reflex activity. The first of these actions has usually been 
considered to show that the alkaloid stimulates Setschenow’s centre in 
the base of the brain; but Dr. Sedgwick (Journ. of Physiology, iii. 22) 
believes that the inhibition is such as occurs when a sensitive nerve is 
galvanized, and is the result of a stimulation of the peripheral afferent 
cardiac pneumogastric nerve-endings. He bases his theory chiefly on 
the fact which he has discovered, that atropine prevents the primary 
inhibition of reflexes by quinine. This is, however, readily explainable 
without the adoption of the theory of Sedgwick, and, as the results 


568 


GENERAL REMEDIES. 


which he obtained after division of the pneumogastrics are scarcely in 
accord with his theory, it is still most probable that quinine is a stim¬ 
ulant of Setschenow’s centre. The cause of the permanent influence 
upon reflex activity has not yet been accurately determined. Chaperon 
and Wild found that the motor-nerve trunks are unaffected, but this 
does not prove that the spinal centres are paralyzed, especially as Wild’s 
experiments seem to show that the nerve-endings in the muscles are 
attacked. (See below.) A. Eulenburg ( Reichert's Archiv , 1865) asserts 
that voluntary movements persist after reflex actions, and that the 
quininized frog will turn into its normal position when laid upon its 
back, although ordinary reflex actions are completely abolished. This, 
if correct, certainly shows that it is either the sensory nerves or the re¬ 
ceptive centres of the cord whose paralysis by quinine puts an end to 
ordinary reflex movements. So that, accepting the various results 
reached by experimenters, it is probable that in frogs quinine first ex¬ 
cites and then paralyzes the peripheral sensitive nervous system. How 
far this applies to man is uncertain. According to the experiments of 
H. Kobert ( Archiv f. Exper. Path. u. Therap ., xv. 49), very large doses 
of cinchonine, and probably therefore of quinine, lessen the excitability 
of the muscles. This is confirmed by the experiments of B. B. Wild 
(Brit. Med. Journ vol. ii., 1887), who finds that solution of quinine one 
to one thousand brought in contact with the isolated muscle of the frog 
diminishes irritability of the muscle and alters to some extent its rela¬ 
tions with stimulation. The peripheral nerve-endings appear to be 
more sensitive than is the muscle, for when a solution of one to four 
thousand was employed galvanization of the nerve failed to elicit a re¬ 
sponse, although the muscle contracted when the current was applied to 
it directly. 

Abdominal Organs. —Upon the stomach and intestines quinine acts 
very much as a simple bitter. In moderate doses it stimulates diges¬ 
tion and increases the appetite ; in large doses it not unfrequently causes 
nausea and vomiting. When there is any morbid irritability of the 
mucous membrane of the stomach or bowels, its irritant action is often 
very marked; and its continued use in large doses has been known to 
cause gastritis. 

Many years since, M. Piorry asserted that a large dose of quinine 
would produce a distinct immediate lessening of the size of the spleen 
in cases of intermittent; but the testimony of very numerous observers 
to the contrary is so concurrent as to render the truth of his observa¬ 
tion highly improbable. Several observers* have stated that the ex¬ 
posed spleen of an animal can be seen to contract when sulphate of 


* M. Piorry, Archives GinSrales de Midecine, 1847; M. Pages, Gazette Medicate, 1846; 
also Dr. Kiichenmeister, Archiv fur Physiol. Heillcunde, Bd. x.; M. Mosler, Pathologie der 
Leulcaemie, Berlin, 1872, p. 451; Jerusalimsky ( Centralblatt f. Med. Wissen., 1876, p. 476). 
The latter observer believes the contraction to be caused chiefly by an action on the peripheral 
splenic nerves and muscles. 



A N TIPER1ODICS. 


569 


quinine is injected into the stomach, veins, or cellular tissue; but other 
investigators* have failed in their attempts to produce this asserted 
contractkm. The experiment necessitates such abnormal exposure of 
the organ that only a very pronounced and very constant diminution 
could establish the assertion that quinine produces contraction of the 
spleen, and our present knowledge indicates that the alkaloid has no 
immediate decided influence on the size of the organ. 

Organs of Circulation , and Blood. —Briquet, who first studied closely 
the action of quinine upon the circulation, found that in large doses it 
lowers the arterial pressure in the lower animals. The experiments 
have been confirmed by various observers, notably by Schlockow (Be 
Chini Sulfavici, etc., Bratisl., 1860), A. Eulenburg ( Reichert's Archiv , 
1865), and Cerna (foe. cit., 194). It has been abundantly proved that 
the alkaloid thrown into the jugular vein, introduced into the coronary 
artery, or in any way brought in contact with the heart, lessens the 
force and frequency of the pulsations, and finally produces diastolic 
arrest; also that this result is not influenced by separation of the 
mammalian heart from the nerve-centres, and occurs in the cut-out 
frog’s heart. In man, very large doses of quinine (thirty to sixty 
grains) lower the force and frequency of the pulse; a pulse-rate of 
forty has been noted, and in reported cases of quinine-poisoning the 
pulse has been imperceptible at the wrist. Under the latter circum¬ 
stances the pulse-rate may be increased, but the cardiac force is reduced 
to a minimum. The evidence is conclusive that both in man and in the 
lower animals quinine in sufficient amount is a 'powerful depressant to the 
heart-muscle or ganglia .f 

Schroff (JSLed. Jahrbucher, 1875) found that in the quininized animal 
neither galvanization of a sensitive nerve nor asphyxia was able to 
produce vascular contraction and rise of blood-pressure, and Jerusa- 
limsky ( Centralbl. f. Med. Wissensch., 1876, p. 476) asserts that in frogs 
dilatation of the vessels could be seen.| Further, Professor Robert, 
experimenting with the excised organs of the warm-blooded animals, 
and Mr. Wild, experimenting with the tortoise, prepai’ed according to 
the method of Dr. Stevens and Donaldson, have found that very weak 
solutions of quinine sulphate (one part to five thousand) cause enormous 
dilatation of the vessels, with consequent increased rapidity of passage 
through them of liquid under pressure. It is probable, therefore, that 


* Magendie ( Gaz. Mecl., 1847), and especially L. T. Bochefontaine, Recherches expSri- 
mentelles d In Contractiliti de la Rate, Paris, 1873. 

■(• Pantellejeff ( Centralbl . f. Med. Wissensch., 1880, xviii. 529) states that atropine will 
cause the heart arrested by quinine to recommence its action. 

J M. Chirone believes that by quinine the heart is arrested in active dilatation. The 
theory is very improbable. See Rivista Clinica di Bologna, abstracted in Journ. de Physiol. 
Norm, et Patholog., 1876, p. 844. 

Heubach, in a series of experiments on the influence of galvanization of a sensitive nerve 
upon the circulation after the exhibition of quinine, failed to detect any paralyzant action of 
the drug, although in some of his experiments the reflex activity was paralyzed. 



570 


GENERAL REMEDIES. 


th q fall of the arterial pressure in poisoning by quinine is in part the result 
of an action upon the vessels. * 

Both Sehroff and Jerusalimsky noticed that the fall of arterial 
pressure produced by quinine is preceded by a rise of the pressure, ac¬ 
companied with an increase of the cardiac action. This observation 
has been confirmed by G-. See and Boehefontaine ( Compt.-Rend. Acad. 
Sci., t. xcvi. p. 267); but no observer seems to have shown that the 
rise of pressure is more than a temporary phenomenon. See and 
Boehefontaine affirm that the increased cardiac action continues some 
time after the pressure begins to fall. The primary rise of pressure 
may be the result of a stimulant action upon the vaso-motor centres, 
as Jerusalimsky found that it was not produced after division of the 
cord. Jerusalimsky attributes the increase in the pulse-rate to paralysis 
of the inhibitory apparatus, a view which is supported by the asser¬ 
tion of Cerna that previous section of the pneumogastric prevents the 
quickening of the pulse-rate. 

I have never been able to perceive any depressant action upon the 
circulation in man after ordinary therapeutic doses (three to five grains) 
of quinine, and I believe that in tonic doses quinine produces no percep¬ 
tible sedation of the circulation, but that the largest antiperiodic doses 
have a distinct influence.f 

According to Bonorn and Arvedi, to Magendie, to Monneret, to Me- 
lier, and to Baldwin, in animals killed with quinine the blood is found 
to be dark, defibrinated, fluid, and incapable of forming a clot. Briquet, 
however, denies that this alteration of the blood is constant, or even 
common, in quinine-poisoning, as he found it in only four out of twenty- 
three dogs so sacrificed; and he believes that it is merely an accident 
dependent upon the method of death,—a conclusion which has been 
confirmed by Dr. H. A. Hare. In a series of analyses Briquet found 
that the continued use of quinine augments the proportion of fibrin, 
but lowers that of the red corpuscles. 

In 1867 1 Professor Binz announced the fact that quinine added to 
human blood in the proportion of one part to four thousand imme¬ 
diately checks and in a short time arrests the amoeboid movements 
of the white blood-cells. Confirmation of this has been furnished by 
Scharrenbroich ( Inaug. Dissert., Bonn, 1867), by Kerner (quoted in 
Practitioner , vol. vii. p. 321), by Geltowsky ( Practitioner , vol. vii.), and 
by Jerusalimsky ( Centralbl. f. Med. Wiss., 1876, p. 476). The minimum 

* When, in Wild’s experiments, the action of quinine was maintained for a length of 
time, the dilatation was finally followed by contraction, which contraction was in all proba¬ 
bility the outcome of a post-mortem rigidity. 

f Some studies have been made upon the action of the drug on the capillaries of the brain, 
but the evidence is contradictory and insufficient. Consult Psychological and Medico-Legal 
Journal, 1875, p. 33; also Archives of Medicine, i. 33. 

J Archiv fur Microscop. Anatomie, iii., 1867, Consult, also, Experimentelle Unter- 
suchungen iiher das Wesen der Chininwirkung, Berlin, 1868; Virchow’s Archiv, 1869, xlvi. 
137; Berlin. Klin. Wochenschrift, Nov. 1871. 



A N TIPERIODICS. 


571 


effective strength of the solution has been found to vary in different 
species of animals, and even in different individuals of the same species. 

It is a matter of great interest to determine whether quinine acts 
in the living organism as on the stage of the microscope; and, to settle 
this point, Professor Binz ( Virchow's Archiv , 1869, Bd. xlvi. p. 138) has 
experimented according to the method of Cohnheim. He found that 
when the mesentery of eurarized frogs to which quinine had been given 
was exposed upon the stage of the microscope, no accumulation of 
white blood-cells in the small vessels, or passage of them out into the 
tissues, occurred upon irritation; or, if after a time these phenomena 
commenced, they were at once checked by a small hypodermic injection 
of the alkaloid. When the inflammatory process had already com¬ 
menced in a “ Cohnheim frog,” an injection of quinine would cause the 
out-wandering of the corpuscles to cease, and would bring about a 
gradual clearing of the white cells from the choked-up vessels. Pro¬ 
fessor Binz further took two young cats, and, after poisoning one of 
them with quinia, examined their blood. In the blood of the un¬ 
poisoned animal the white cells were far more abundant than in that 
of the poisoned cat. From these facts Professor Binz deduces the con¬ 
clusion that quinine acts destructively in the system upon the white 
blood-corpuscles, in the same way as when they are out of the body. 
Dr. Geo. It. Cutter ( Psycholog. Medico-Legal Journ., Feb. 1875) and Dr. 
H. A. Hare ( Phila . Med. Times , xv. 43) have experimentally confirmed 
the effect of quinine in preventing the extrusion of white blood-cells 
from the frog's mesentery, and A. Martin* ( Inaug. Dissert., Giessen, 
1868) has also found that the action of the drug is apparent in the 
centre of parenchymatous organs, such as the liver. 

On the other hand, Schwalbe f could detect no difference in the 
blood of a cat before and after poisoning by quinine; and the experi¬ 
ments of Geltowsky (Joe. cit .) upon frogs and guinea-pigs have yielded 
similar results: in all cases after fatal poisoning by the alkaloid the 
movements of the corpuscles were found to be very active. 

The correctness of the original observation of Professor Binz upon 
the out-wandering of the white blood-corpuscles in the Cohnheim frog 
must be considered as established, but it is not proved that the failure 
of the blood-corpuscles to escape from the irritated vessels is due to the 
arrest of their amoeboid movements by the quinine. In a series of ex¬ 
periments Dr. H. A. Hare (loc. cit.) found that the vessels in the cin- 
chonized froc* were much more contracted and had their walls much 
thicker than in a corresponding frog without quinine. This contrac¬ 
tion of the vessels is thought by Dr. Hare to be the result of a direct 
action exerted by the drug upon the muscular coat of the arterioles. It 
is certain that the alkaloid reduces very markedly the force of the 


* Quoted by Binz, Virchow’s Archiv, Bd. xlvi. p. 137. 
f Quoted by Kerner, Pjiiiyer’s Archiv, Bd. i. p. 203. 



572 


GENERAL REMEDIES. 


heart. It is, therefore, possible that the quinine prevents the out- 
wandering by lessening the force which is driving the corpuscles and 
at the same time increasing the resistance of the capillary walls. It 
must be considered still doubtful how far quinine affects the white 
blood-corpuscles in the circulation even when it is administered in poi¬ 
sonous doses. When therapeutic doses are employed, the doubt as to 
its powers is of course still stronger. 

It would seem that quinine acts also upon other portions of the 
blood than the white corpuscles. Manassein ( Ueber die Dimensionen der 
rothen Blutkorperchen unter verschiedenen Verhdltnissen , Berlin, 1872) 
has found that in fever occurring in the lower animals the red corpus¬ 
cles are diminished in size. If in this condition a decided dose of an 
antipyretic, such as quinine or alcohol, be given, and the temperature 
falls, the globules resume their normal size. That the change is due to 
the fall of the temperature rather than to a direct action of the drug 
is, I think, demonstrated by the fact of its occurrence whenever the 
fever-heat is lowered by the application of external cold. The experi¬ 
ments of Manassein, therefore, do not prove that quinine exerts any 
direct action on the red corpuscles. The investigations of Binz {Arch, 
f. Exper. Path. u. Pharm., Bd.i., Heft i., 1873), however, appear to show 
that the alkaloid lessens the ozonizing power of the blood; for he 
found that in young cats to which he had given a very large but not 
fatal dose of quinine the freshly-drawn blood affected the tincture of 
guaiac much less than it normally should. 

When blood is drawn from the body and allowed to stand, acid is 
developed in it. Zunst ( Inaug. Dissert ., Bonn, 1868), who has studied 
this subject most closely, divides the investigation into study of the 
production of acid in the time from the escape of the blood from the 
vein to its coagulation, and study of the slow changes which increase 
its acidity when coagulated until putrefaction has fairly set in. Pro¬ 
fessor Binz believes that this development of acid is due to oxidation, 
and by an elaborate series of experiments has determined that quinine 
(also sulphate of bebeerine and picrate of sodium in almost as great 
degree) inhibits these changes very greatly in both their varieties. 
These experiments are in accord with the previous ones of A. Schulte 
(Centralbl. f. JSled. Wissensch., Nov. 1871): the facts may, therefore, be 
considered proved. 

If ozonized oil of turpentine be dropped into an alcoholic solution 
of guaiac resin, no alteration of color occurs; but if a drop of blood 
be added, the blue appears at once: i.e., the blood acts as a carrier of 
ozone from the turpentine to the resin. Professor Binz has found that 
quinine, even in so small an amount as one part in twenty thousand, 
has a perceptible influence in preventing this. Similarly, when into a 
dilute watery solution of the sulphate of indigo carbonate of sodium is 
thrown until the reaction is decidedly alkaline, and a little blood, and 
subsequently ten drops of ozonized turpentine, are added, a green color 


A N TIPERIODICS. 


573 


begins at once to develop, and in a little while passes into the clear 
yellow of isatin. In this case also the blood acts as a carrier of ozone; 
and Binz and his pupil Ransone ( Inaug. Dissert Bonn, 1871) have 
found that quinine also inhibits this action, one part of it added to a 
thousand of the mixture delaying the change of color for an hour. In 
these experiments Binz used a large number of different salts of qui¬ 
nine, and found that they acted identically. That the action of the 
alkaloid was on the blood, not on the indigo and guaiac solutions, was 
shown by the fact that when similar solutions without the blood were 
shaken in the air and absorbed ozone, the characteristic colorations of 
its action were produced just as readily when quinine was absent as 
when it was present. Binz also proved that the red corpuscles were 
the portions of the blood affected. On adding crystallized hemoglobin 
from horses’ blood to the ffuaiac solution he found that it acted as an 

o 

ozone-bearer between the turpentine and the guaiac, and further demon¬ 
strated that quinine had the power of preventing this action. 

As it is established that quinine exerts some antipyretic action 
(see p. 580) in ordinary fever, it is an exceedingly plausible theory that 
the lowering of temperature is due to a checking of the ozonizing 
power of the blood. To attribute, however, the general medical virtues 
of quinine to an action on the white corpuscles seems to me unreason¬ 
able; for from the experiments of Professor Binz himself upon the 
lower organisms it would appear that quinine acts upon all animal ger¬ 
minal matter; and it is probable that the protoplasm of the nervous 
system, being more specialized than that of the white corpuscles, 
would be more susceptible to the influence of the alkaloid. Professor 
Binz states that both conine and camphor act more forcibly upon the 
white corpuscles out of the body than does quinine, and Drs. T. Lauder 
Brunton and Theo. Cash have found that morphine, veratrine, and 
codeine check the ozonizing power of the blood, while digitaline, 
picrotoxine, and caffeine increase it. Each of these principles has its 
own peculiar physiological action, differing from that of quinine and 
the other alkaloids (St. Bartholomew's Hosp. Bep., xviii. 269). It seems, 
therefore, to me absurd to attribute such diverse ph}’siological actions 
to the one common property of the group, and I think that we must 
consider the antozonizing power of quinine as simply one of its func¬ 
tions, and not as the basis of all its relations with the human organism. 

Antiseptic Action. —As long ago as 1765, Dr. Pringle ( Observations on 
Diseases of the Army, London, 1765) called attention to the fact that 
cinchona bark, in decoction or powder, has the power of preventing for 
a time putrefaction in flesh ; and more recently the subject has been 
studied by Mayer, by Pavisi, by Hallier ( Das Cholera-Contagium, Leip- 
sic, 1867), by Herbst, by Polli, and especially by Binz ( Virchow's Archiv, 
1869, Bd. xlvi. p. 68; and Untersuchungen uber das Wesen der Chinin- 
wirkung , p. 20), to whose elaborate articles I must refer my readers for 
details and references. The experiments of these authorities have de- 


574 


GENERAL REMEDIES. 


monstrated that quinine in the proportion of one part to three hundred 
will preserve for a long time flesh, meal, milk, butter, urine, albumen, 
etc., and will check very markedly the alcoholic fermentation in honey 
or in syrup. Professor Binz has proved that this antiseptic action 
is due to a poisonous influence exerted by the quinine upon the fungi 
which are the immediate cause of the changes. According to his ex¬ 
periments, the larger infusoria, such as Paramecia and Colpoda, are 
killed by a solution of quinine of the strength of one in eight hundred 
immediately, of one in one thousand after some minutes, of one in 
twenty thousand after some hours. Upon the ordinary mould Penicil- 
lium, upon Vibrios and Bacteria, as well as upon the higher infusoria, 
quinine acts with a similar fatality. In the case of the Vibrios and 
Bacteria a decidedly stronger solution than the one mentioned is re¬ 
quired to quiet movement. Bochefontaine ( Archives de Physiologie , 
July, 1873) found that a solution of one per cent, was needed for a 
vigorous rapid action, and that some active granules could even be found 
in it after three days. According to Binz, the singularity of the influ¬ 
ence of quinine is shown by the fact that a solution of salicin in the 
proportion of one part to forty does not kill Paramecia and Colpoda. 
Indeed, these infusoria were not even affected by this strong solution 
of salicin, and they endured a solution of morphine of one part to one 
hundred and twenty for an hour, and a five-per-cent, solution of strych¬ 
nine for some minutes. Although fungi will appear after a time in 
ordinary solution of the sulphate of quinine, I think it must be con¬ 
sidered well established that this and other salts of the alkaloid are 
extremely poisonous to the fungi of putrefaction and of other ordinary 
fermentations. 

Uterus. —In 1871, Dr. Monteverdi announced (Annales et Bulletin de 
la Societe de Medecine de Gand , May, 1871) that quinine is a uterine 
stimulant, causing at times in the gravid womb contractions sufficiently 
violent to induce abortion, and, when given during labor, intensifying 
greatly the uterine pains, and after labor causing rapid expulsion of 
the placenta and arresting uterine hemorrhage; affirming, further, that 
in amenorrhoea or in menorrhagia from uterine inertia its action is no 
less marked. Although this has been received as new the world over, 
so long ago as 1855 Dr. John S. Wilson ( Southern Medical and Surgical 
Journal , p. 341, 1855) called attention to the uterine action of quinine, 
and in 1860 reasserted his belief ( Southern Journal of Medicine , Sept. 
1860), which in the mean while had been confirmed by Dr. J. H. Eich 
in the Charleston Medical Journal and Review; and in 1858 Dr. Jos. J. 
West ( Savannah Journal of Medicine , i. 19) wrote, ;t Many regard the 
use of quinine as dangerous and even criminal in any diseases in preg¬ 
nant women. The belief of these persons is that this substance exer¬ 
cises a direct influence upon the uterus, causing powerf ul contractions and 
expulsion of the foetus. And to support this notion they are ready to 
bring forward innumerable instances of abortion after its use,—of cases 


ANTIPERIODICS. 


575 


of sudden suppression relieved by a prompt use of the same remedy.” 
He then goes on to say that these abortions, etc., were due to the inter¬ 
mittent fever and not to the drug. Surely this is enough to show that 
the oxytocic action of quinine was believed in many years ago by num¬ 
bers of our Southern practitioners. The question now is whether the 
drug has any such action. It is evident that the answer to this should 
be made out in three different ways. First, Is there any evidence of 
quinine producing abortion in healthy women or in females of other 
animals ? Second, How strong is the evidence of its producing abortion 
in women suffering from ague ? Third, What is the evidence in regard 
to the action of quinine during labor ? 

In regard to the first of these sub-questions, the only affirmative 
evidence I have met with is in the experiments of M. Rancillia ( L ’ Union 
Medicale , 1873), who saw abortion in two bitches follow the administra¬ 
tion of from six to nine grains of quinine: as the pups in one case were 
already dead before the administration of the drug, it would seem that 
this investigation was not on such a scale as to be at all conclusive. 
Moreover, I have given quinine to two pregnant cats, in one case in 
sufficient quantity to cause death, without disturbing the products of 
conception. Furthermore I have met with no evidence that quinine is 
capable of inducing abortion in healthy pregnant women. Dr. Sayre’s 
case ( American Practitioner , 1871, p. 260) is certainly no proof what¬ 
ever that quinine will originate labor, as labor had commenced under 
the influence of the hot and cold douche and other measures employed 
before the quinine was given. Professor Chiara, of Milan, has furnished 
( L' Union Medicale , Nov. 20, 1873) very strong evidence that quinine 
is incapable of originating uterine contractions in healthy pregnant 
women. In his public service, two doses of a gramme (15.34 grains) 
each were given without effect daily for two successive days to eight 
women all in the eighth month of pregnancy. It being necessary to 
cause abortion, one gramme was given daily to one woman for seven 
days, to another for three days, without in either instance any effect, 
so that the labor had to be brought on in the usual manner. On the 
whole, I believe that the first question must at present be answered in 
the negative. 

In answer to the second sub-question, some evidence has already 
been adduced to show that abortion may be so caused. To it may be 
added the assertion of Dr. Walraven ( Bost . Med. and Surg. Journ ., 1873) 
that he has frequently seen the exhibition of quinine followed by abor¬ 
tion, the record of two cases of such character by Dr. Burt ( Medical 
and Surgical Reporter, 1870), and no doubt the affirmations of others 
which I have not seen. Opposed to this, however, is the overwhelming 
fact that the great body of the profession have for centuries been giving 
quinine in one form or other to pregnant women indiscriminately, and if 
abortion had been produced it must have been noted long ago. Further, 
direct testimony is not wanting. Malaria often induces abortion, and 


576 


GENERAL REMEDIES. 


Dr. Erwin (St. Louis Medical and Surgical Journal , March, 1872), Dr. 
Jas. C. Harris (American Practitioner, April, 1872), and Dr. A. Russ- 
wurm (American Practitioner , 1871, No. 4, p. 127) testify from personal 
experience that quinine will arrest abortion from such cause. Dr. J. 
A. Ashford (National Medical Journal , Oct. 1871), Dr. Beauchamp 
(American Practitioner , 1870), Dr. Rooker (Ibid.), Dr. J. S. May (Ibid.), 
and Dr. A. d’Arcourd (Medical News and Library , May, 1873) have 
given the alkaloid to hundreds of pregnant women in large doses with¬ 
out result. Other testimony might be adduced; but it seems to me 
incredible, in the face of daily experience, that even the largest thera¬ 
peutic doses of quinine are abortifacient in malarial fevers or in health. 

In regard to the third sub-question,* it seems to me proved that 
quinine in full doses (ten to twenty grains) is a very powerful stimu¬ 
lant to the uterine contractions during labor. The pains it produces so 
exactly simulate the natural ones as to indicate that they are not so 
much caused by a specific action of the drug as by its arousing the 
general nervous forces of the system. Be this as it may, most of the 
leading accoucheurs of this city and of New York are accustomed to 
rely upon quinine in cases of uterine inertia from exhaustion.f 

Kidneys and Elimination. —The manner in which quinine finds en¬ 
trance into the blood has been especially studied by Dr. Kerner (loc. 
cit.). As the gastric juice is very acid, it is evident that the alkaloid 
will be rapidly dissolved in the stomach and be put into the conditions 
most favorable for its absorption : if, however, the salt of quinine escapes 
from the stomach into the intestines, it will bo liable to be precipitated 
by the alkaline juices, as well as by the bile, whose acids form very in¬ 
soluble salts with it. The presumption is therefore strong that, ■when 
gastric absorption fails to take place, at least a portion of the quinine 
will pass out with the faeces. That this actually does occur has been 
proved by Kerner and others, wdio have found the alkaloid in the ex¬ 
crement of persons taking it. As the blood is alkaline, it would ap¬ 
pear probable that the quinine salt so soon as entering it would be 
precipitated. That this does not occur, according to the researches of 
Kerner, is due to the solvent power of the gases contained in normal 
blood. 

The authority mentioned found that one thousand parts of blood 
which was defibrinated and deprived of its gases, at a temperature of 


* For details of the evidence the reader is referred to the third edition. Consult also 
Practitioner, xvii., xviii., xix. 

f Certain experiments of Wild {Brit. Med. Journ., vol. ii., 1887) suggest that the quinine 
may act directly upon the muscle-fibres of the uterine walls. He found that when the solution 
of quinine sulphate, one part to a thousand, was brought in contact with the isolated oesopha¬ 
gus of the frog, the oesophagus first shortened, and afterwards lengthened beyond its normal 
limit, the change probably being, as believed by Wild, due to stimulation first of the weak 
longitudinal muscular fibres, and later of the more internal stronger circular fibres, as the 
quinine penetrated the coats. The muscle-fibres of the oesophagus are similar to those of the 
uterus. 



ANT1PERI0DICS. 


577 


36° C. dissolved in an hour only 0.398 part of pure quinine. Water 
saturated with carbonic acid gas dissolves the sulphate of quinine 
pretty freely; and Kerner also experimentally determined that when 
a neutral solution of a salt of quinine is added to a very dilute solu¬ 
tion of carbonate of sodium no precipitate occurs. It would appear, 
then, that the quinine is held in solution in the blood by reason of the 
loosely-combined carbonic acid gas in that fluid. 

It has been proved by the analyses of Landerer (j Repertorium fur 
Pharmacie , 13d. xxv., 1836), of Dietl ( Wiener Medizinische Wochen- 
schrift, 1852), of Briquet (loc. cit .), of Binz, and of De Benzi ( Bull. 
Therap ., t. xci. p. 45), that quinine escapes from the body through the 
kidneys. According to Briquet, it may generally be found in the urine 
half an hour after the administration of a large dose. Its removal, 
according to the researches of Binz, goes on slowly, for it is stated (loc. 
cit., p. 167) that in six experiments only a little more than two-thirds 
of the ingested quantity was excreted in the first forty-eight hours. 
Further, De Benzi, Yvon, and Diet! (Pie Pjianzenstoffe, 1883, p. 1443) 
have found it in the urine six or seven days after the ingestion of the 
last dose. Dr. L. Thau, however, in three experiments, out of the 4.4586 
grammes of the alkaloid w r hich were given, recovered from the urine 
passed during the forty-eight hours 4.3 grammes, so that only 0.1586 
gramme remained unaccounted for. A portion of this residue was 
perhaps lost in the chemical operations; but it is probable that some 
of the quinine is eliminated through other channels than the kidneys, 
since Professor Binz has found it in the saliva of a poisoned dog, and 
Landerer (Buchner s Repertorium , 1839 and 1842) states that he has 
detected it in the urine, sweat, tears, milk of nursing women, and in 
the serum of dropsical effusions, while Albertoni and De Benzi find it 
abundant in the bile when it has been taken by the mouth, but not 
when it has been given hypodermically. Dr. Thau determined that 
from a third to somewhat less than half of the ingested quinine escapes 
from the body in the first six hours, and that in the first twelve hours 
about three-fourths are excreted * Welitschkowski found (St. Petersb. 
Med. Wochenschr., 1876) an elimination of sixty-five per cent, the first 
day, and twenty-five per cent, the second day. Prior gives the second 
day as the usual final limit of elimination. I think we may consider 


* Dr. G- Kerner ( Pfuger’s Archiv fur Physiologic, 1870) asserts that the quinine as ex¬ 
creted is in an amorphous, uncrystallizable form. He also has discovered in the urine of 
persons taking quinine a peculiar substance, sometimes amorphous, sometimes in acicular 
prismatic crystals, free from bitter taste, possessing the quinine inflorescence, which he be¬ 
lieves to be a derivative formed in the body from the ingested alkaloid. He has not been 
able to get this substance in such quantity as to analyze it or further examine it, but has 
produced a principle (dihydroxyle quinine) which he believes to be identical with it by acting 
on quinine with the permanganate of potassium. An elaborate series of experiments have 
shown that the dihydroxyle quinine is physiologically inert. This dihydroxyle quinine must 
be produced in small amount, if at all, as there is abundant evidence that quinine is largely 
excreted as quinine (see Pharm. Journ. and Trans., ix. 125). 

37 



578 


GENERAL REMEDIES. 


that after a few doses the alkaloid is practically eliminated in forty-eight 
hours, but that when it has been given continuously, or when kidney- 
disease or great feebleness of circulation exists, the system may contain 
a notable amount of the quinine for a longer period. The researches 
of Welitschkowski are in accord with those of Jurgensen and Thau in 
showing that in cardiac and renal disease and in low fevers elimination 
proceeds very slowly, more of the alkaloid being thrown off in the 
second than in the first six hours after its ingestion. 

Eanke was, I believe, the first to notice that quinine produces a 
great decrease in the elimination of uric'acid. This was confirmed by 
H. Y. Bosse ( Inaug. Diss., Dorpat, 1862) and by Dr. G. Kerner ( Pfluger's 
Archiv, 1870, iii. 93). The latter observer found that, when about nine 
grains of quinine were taken in divided doses during the course of the 
day, the urea was decreased not quite one-eighth, the uric acid to a 
little less than one-half, the kreatinine was slightly increased, and the 
nitrogenous material decreased about one-ninth. When a very large 
dose (thirty-eight grains) was taken in the morning, the urea and the 
kreatinine were each decreased about one-fourth, as was also the collec¬ 
tive nitrogenous material; the phosphoric acid was lessened about one- 
fifth, and the uric acid about four-fifths. Zuntz (quoted by G. Strass- 
burg, Archiv fur Exper. Path., Bd. ii. p. 343) found that twenty-five 
grains of quinine reduced his elimination of urea nearly forty per cent. 
A. Schulte also found 1.8 grammes of quinine depress the elimination 
by the kidneys thirty-nine per cent. (Inaug. Piss., Bonn, 1870); yet 
in the experiments of Unruh (Virchow's Archiv, 1869, xlviii. 227) the 
action of the alkaloid in depressing urea elimination was not constant, 
and in the trials of II. Oppenheim (Pfluger's Archiv, 1880, xxxiii. 446) 
the excretion of urea was actually increased. Nevertheless, the experi¬ 
ments, upon the dog, of Rabuteau (Bull. Tlierap., lxxv. 475) and of 
Hermann von Boeck ( TJntersuchungen uber die Zersetzung des Eiweisses 
im Tlxierkbrper, Munich, 1871), bear strong evidence to the fact that 
quinine does decrease the elimination of urea; and the recent very 
elaborate studies of I)r. Prior (Pfluger's Archiv, Bd. xxxiv. p. 237) war¬ 
rant us in believing it established that quinine powerfully depresses the 
elimination of the nitrogenous excretory principles. That such decrease 
is due to diminished formation, and not to lessened elimination, seems 
proved by the fact that in Prior’s experiments there was no increase 
of nitrogenous excretion beyond the norm following the omission of 
the quinine. It seems to be established that quinine has a direct or 
indirect depressing influence upon the tissue-changes of the human organism. 

Contrary to what might have been expected, Strassburg, in an elab¬ 
orate series of experiments, found that quinine had no decided effect 
upon the elimination of carbonic acid either in healthy or in fevered 
rabbits. These observations of Strassburg are opposed by those of 
Boeck and Bauer (Zeitschr. fur Biolog., Bd. x.), who found that in cats 
large doses of the alkaloid cause in the first stage of their action les- 


ANTIPER10DICS. 


579 


sened carbonic acid production, but that when the convulsions appear 
the carbonic acid is increased as the result of the increased muscular 
activity. Professor R. H. Chittenden ( Studies from the Laboratory of 
Yale University , vol. ii. p. 223) found that fatal doses of quinine given 
to fasting rabbits had no decided effect upon carbonic acid production 
until just before death, when both the animal temperature and the 
excretion of carbonic acid fell distinctly. On the other hand, small 
doses of quinine seemed to cause a gradual falling off in the carbonic 
acid elimination. Although the evidence is somewhat contradictory, it 
appears to show that any action of quinine upon carbonic acid elimi¬ 
nation must be very feeble and uncertain. 

Therapeutics.— At present our estimate of the value of quinine in 
disease, and our knowledge of its therapeutic use, rest solely upon clin¬ 
ical observation, although recent researches have enabled us to frame 
at least a plausible exjdanation of the method in which it overcomes 
malarial disease. 

On account of its power of arresting or preventing putrefactive 
fermentation by killing the microscopic entities which produce such 
changes, Professor Binz has recommended it in the so-called septic dis¬ 
eases. The chief evidence which he produces is in some ten experi¬ 
ments made upon dogs and rabbits. In each of these experiments two 
similar animals were poisoned with putrescent liquids, and to one of 
the pair quinine was freely administered. In two cases the cincho- 
nized animal recovered, while its fellow perished; in three experiments 
neither of the animals died; and in the other five trials the cincho- 
nized animal lived from two to twenty-four hours longer than the other. 
These experiments are certainly too few and indecisive to prove in any 
degree Professor Binz’s view. To my mind they indicate very strongly 
that quinine has no such influence over the disease as he claims for it. 
If living germs in the blood were really the cause of the septic sj^mp- 
toms, and if quinine killed such germs, its action would be as manifest 
and as unmistakable as it is in intermittent fever. The results of Pro¬ 
fessor Binz’s experiments indicate no such specific action, but rather 
that the quinine in such cases does good by sustaining the nervous sys¬ 
tem, or in some other unknown manner. In pycemia in man, quinine 
has been frequently employed, but exerts no specific action. 

It has not, that I know of, been proved that therapeutic doses of 
quinine lower, to any marked extent, bodily temperature in the healthy 
man. Dr. G. Kerner and Dr. Jiirgensen have each noticed that full 
doses of quinine appear in a healthy man not to affect sensibly the 
temperature, but to prevent the rise which normally occurs from exer¬ 
cise. Thus, in Kerner’s experiment, certain gymnastic exercises, which 
when performed in his ordinary state elevated his bodily temperature 
2° C., affected the latter to the extent only of 0.2° to 0.35° C. when 
quinine was freely exhibited. 

Even Dr. C. Liebermeister ( Deutsch . Arch. f. Klin. Med ., 1867, Bd. 


580 


GENERAL REMEDIES. 


iii.) acknowledges that numerous experiments have shown him that 
the alkaloid has no constant action on the bodily heat in health, and 
details a case in which forty grains administered within seven hours 
caused no depression of temperature. The same authority claims, 
however, that by a very large number of experiments he has demon¬ 
strated its power of lessening fever-heat. In one hundred and seventy- 
eight observations in typhoid fever, twenty grains of the quinine having 
been given during the night, the morning temperature was lower than 
that of the previous evening by, on the average, 1.63° C. On one 
hundred and seventy-six different occasions a scruple of quinine was 
given during the day; sixty-nine times the temperature was lower in 
the evening than in the morning, ten times it was the same as in the 
morning, and ninety-seven times it was higher than in the morning. 
A committee appointed by the London Clinical Society ( Transactions , 
1870, vol. iii. p. 201) experimented with the drug on about fifty cases 
of various diseases. They assert that the antipyretic action of large 
doses was very decided, appearing within from one to two hours after 
the exhibition of the drug, and lasting from a few to many hours. In 
a very recent publication Liebermeister states that he has given some 
ten thousand doses of quinine as an antipyretic and has almost un¬ 
bounded confidence in it. He insists that from twenty to forty-five 
grains must be given within the hour , and not repeated oftener than once 
in twenty-four or forty-eight hours. 

Naunyn and Quincke ( Reichert's Archiv, 1869) found that some¬ 
times quinine prevented the development of fever after the division 
of the spinal cord in animals, but in other cases failed to do so. Binz 
(.London Practitioner , p. 4, 1870) has achieved similar results: he says 
that if the conditions of the fever are too favorably constituted the 
effect of the quinine fails thoroughly. The drift of our present clinical 
evidence seems to indicate that quinine exerts in febrile disease a decided 
antipyretic action, which is especially manifested during those stages 
of disease in which the natural tendency is towards a lowering of 
temperature. In typhus and typhoid fever , scarlatina , severe erysipelas , 
rheumatic hyperpyrexia , etc., after the use of the cold bath (see Part I.) 
twenty grains of the alkaloid are often efficacious in delaying the re¬ 
turn of the excessive fever. If the experiments spoken of above be 
correct, this reduction of temperature must be due to an action on 
the tissues and not on the central nervous system. It would seem, 
however, more probable that quinine acts as an antipyretic by stimu¬ 
lating the inhibitory chemical centre ; but decision of this must be 
reserved for future investigations. As an antipyretic the drug may 
be used whenever there is serious elevation of temperature, except it 
be in cases of simple inflammation of the brain or its membranes. All 
antipyretic remedies appear to act more strongly on children than on 
adults; and accordingly Dr. Rapmund ( Deutsche Klinik , 1874, p. 51) 
has found quinine of the utmost service in serious diseases of children 


ANTIPERIODICS. 


581 


with high temperature, especially lobular pneumonia. Much of the 
failure which has hitherto attended its employment undoubtedly has 
been due to a faulty method of administration. 

As a simple tonic, quinine is largely used, especially in combination 
with iron. I am not entirely convinced that it is of much more value in 
simple debility than is quassia or other simple bitters; but if, as is prob¬ 
able, it be true that quinine lessens to a very great extent the elimina¬ 
tion of nitrogen, i.e., the consumption of tissue, the general practice is 
well founded. Dr. Hare ( Boston Med. and Surg. Journ., vol. cxiv. p. 73), 
as the result of observations made upon himself, believes that quinine 
has a distinct action in increasing the formation of the red blood-cor¬ 
puscles. If this be correct, it must have especial value as a tonic. 

When administered in very large doses, quinine, as has been already 
shown, acts as a powerful depressant, and as such it has been used by 
Briquet and other French physicians in rheumatism. As much as sixty 
or seventy grains a day have been given, and it is beyond dispute that 
under the influence of these heroic doses the symptoms of inflammatory 
rheumatism have often rapidly abated; but the method has found little 
favor out of France, and is less efficient and more dangerous than other 
plans of treatment now in vogue. 

In inflammatory rheumatism, after the acute symptoms have abated, 
when the patient shows evident signs of weakness, especially if there 
be profuse sweating during sleej), fifteen grains of quinine daily are 
often of great service. 

Quinine and its salts have the remarkable property of converting 
the chemical rays of the spectrum into light, or, in other words, of 
rendering visible the ordinary invisible rays of the solar or other spec¬ 
trum. Connected with this fact is probably the phenomenon known as 
the fluorescence of quinine. AVhen a colorless watery solution of one 
of its salts is examined, a pale-blue line upon the surface is very notice¬ 
able; and Professor Stokes has shown that solution of quinine has 
the power of entirely stopping certain of the rays of light, so that 
when a beam is transmitted through it to light up a second vessel of 
the solution this latter displays no fluorescence. Dr. H. Bence Jones 
(.Lectures on Pathology and Therapeutics , London, 1867) has found that 
when the electric light is used this test is so delicate that one grain of 
the alkaloid may be detected in 1,450,000 grains of water. He has 
also discovered that man and animals are pervaded by a substance 
which, in its action on light and in many chemical reactions, very 
closely resembles, if it be not identical with, quinine. Believing this 
substance to be probably an alkaloid, he has given it the name of 
animal quinoidine. Drs. Edward Rhoads and William Pepper, Jr. 
(.Pennsylvania Hosp. Reports , vol. i., 1868), have made observations upon 
ten cases of malarial fever in which no quinine had been used, and 
have found the fluorescence of the blood to be from 0 to 1£, instead of 
from 3 to 6, which is said to be normal. Dr. Chalvet ( Schmidt's Jahrb., 


582 


GENERAL REMEDIES. 


Bd. cxli. p. 152) has, however, shown that this fluorescent substance 
exists in various foods, and is probably of vegetable origin, so that it 
is extremely unlikely that there is any pathological connection between 
the absence of the fluorescent body from the blood and malarial fever. 

The researches of Laveran, of Marchiafava and Celli, of Osier, and of 
Councilman render it probable that malarial disease is caused by certain 
organisms in the blood. Of these organisms, at least three different 
forms have been detected. In one of these forms rapid multiplication 
by segmentation is going on. According to the investigations of Pro¬ 
fessor Osier, confirmed by Dr. Councilman, this segmenting organism is 
found only in or about the chill period of the acute malarial paroxysm. 
The second form of the organism is a quiescent crescent, which is found 
only in cases of malarial cachexia. The third supposed stage or form 
of organism is flagellate; but no connection has as yet been made out 
between this and any special stage of malarial poisoning. Dr. Council¬ 
man has found that fifteen grains of quinine given daily for several 
successive days usually arrest the paroxysm of an intermittent, and at 
the same time greatty lessen the number of segmenting organisms in 
the blood. In his cases after several daily doses of twenty-five grains 
the segmenting organism always entirely disappeared. No effect upon 
the crescentic organisms was produced by even excessive doses of qui¬ 
nine or of arsenic. As the value of these therapeutic agents in chronic 
malaria is thoroughly established, it is at present not possible to ex¬ 
plain why they do not affect the crescentic organisms: it is indeed not 
altogether certain that these represent one of the life-stages of the seg¬ 
menting organism and have etiological connection with malarial fever. 

Quinine in its relations to malarial fever may be considered first as 
a prophylactic, secondly as a curative agent. 

The value of the daily use of quinine to persons exposed to a mala¬ 
rial atmosphere has now been thoroughly tested in all portions of the 
world. In North and South America, in Europe, in Africa, in India, 
the prophylactic powers of quinine have been tried on the largest scale 
in connection with the military and naval services, and the testimony 
is unanimous in favor of the drug. A single citation will serve to illus¬ 
trate this fact.* Dr. J. B. Hamilton (Indian Medical Gazette , Nov. 1, 
1873) reports the case of a battery of one hundred and thirty-five men ; 
quartered at Jubbulpore, East Indies, in the same barracks with an 
infantry regiment. Each of the artillerists received three grains of 
quinine every other day; to the infantry none was given. The result 
was that while three hundred out of the five hundred men of the regi¬ 
ment were sick at one time with malarial disease, at no period was more 
than four per cent, of the battery affected. The dose of quinine as a 
prophylactic may be considered as three grains in the morning and two 
in the evening. 


* See also K. M. Downie, M.B., Indian Medical Journal, March 1, 1872. 



A NTIPERI ODICS. 


583 


In intermittent fever, when there is sufficient time, it may be well to 
precede the quinine by a mercurial or other purge. If the expected 
paroxysm be so near that there is not sufficient time for the action of 
the purgative, the antiperiodic should be administered without previous 
preparation of the patient. The value of purgatives in obstinate inter- 
mittents, as an adjuvant to quinine, is often overlooked, although in 
some cases the employment of purgatives, and of such diuretics as 
cream of tartar, seems to be almost essential for its successful use. 

When there is necessity for prompt action, the antiperiodic may be 
given in a single dose, or in any other method that the circumstances 
of the case will allow; but ordinarily the best plan is to commence the 
exhibition of the drug about eight hours before the expected paroxysm, 
and to continue in hourly doses until from three to four hours before 
the attack is due. 

In pernicious fever , or malignant malarial poisoning , no time should 
be lost after the first paroxysm in getting the patient cinchonized, as it 
may be uncertain whether the attack be of the quotidian or of the tertian 
type. At least thirty-five grains of the alkaloidal salt should be admin¬ 
istered during the first twenty-four hours of intermission, and twenty- 
five grains during the second; in very severe types of the disease much 
larger doses even than these are necessary, less than fifty grains of the 
drug sometimes appearing to do but little good. 

In remittent or bilious fever it may often be advisable to give purga¬ 
tives and febrifuges, but it is not proper to delay the exhibition of the 
antiperiodic on their account. As soon as the remission has appeared, 
the exhibition of quinine should be begun. Local inflammations or 
even severe cerebral 83 ’mptoms occurring during a remittent fever are 
no contra-indications to the use of the specific. When gastritis exists, 
other channels of entrance than the stomach should be employed, on 
account of the local irritant action of quinine. 

When the symptoms in remittent fever are severe and seemingly 
continuous, it may be not only proper, but necessary for the saving of 
life, to exhibit quinine freely during the period of fever. In large doses 
the alkaloid is probably antipyretic as well as antiperiodic, and I do not 
know of any theoretic or clinical objection to its use during the period 
of fever. 

In malarial intermittent neuralgia , as in all other forms of abnormal 
manifestations of malarial disease, quinine is efficient, although it may 
be necessary to use it in large doses. 

In neuralgia which, although not dependent upon malaria, assumes 
the intermittent type, quinine will often temporarily set aside the parox¬ 
ysmal attacks, and sometimes effect a cure. The same fact may be 
stated in broad terms as true of all non-malarial intermittent affections. 
In the great majority of such cases, unfortunately, the action of the 
quinine is only temporary, and any controlling power is soon lost. 

The amount of quinine required in ordinary cases of malarial fever, 


584 


GENERAL REMEDIES. 


and the method of its administration, have been the subjects of almost 
endless discussion. As the result of much experience and reading, I 
am convinced that it is better to use the remedy in large doses at in¬ 
tervals than to administer it continuously in smaller amounts. In this 
climate twelve grains of quinine a day will usually put an end to a 
mild intermittent, but the paroxysm will be very apt to recur, even if 
six grains of the alkaloid be afterwards given daily for some weeks. 
I believe it is better to administer from fifteen to twenty grains in 
the beginning, sufficient to produce very pronounced cinchonism and 
to arrest the disease at once. The full physiological effect of the drug 
should then be maintained for two or three days, and no more of it 
given except at regular intervals. The paroxysms have undoubtedly 
a great tendency to return on the seventh day after their arrest, and 
every seventh day for some weeks full cinchonism should be produced. 
If the observation of Councilman that large doses of quinine entirely 
destroy the malarial organism be correct, the practice just spoken of 
has a foundation in scientific as well as in empiric observation. 

Various idiosyncrasies exist towards quinine. Professor Ivaramitsas 
asserts that in some persons it produces haematuria (Bull. Therap., xcvii. 
53): it not very rarely causes vesical irritation, and it is said that in 
some people (Brit. Med. Journ., ii., 1869 ; Berlin. Klin. Woch., 1877, 294; 
Phila. Med. Times, x. 166) a few grains given internally suffice to pro¬ 
duce great oedema of the face and limbs, accompanied with a pronounced 
erythematous rash, in some cases closely resembling that of scarlatina 
(N. V. Med. Record , xxi. 627), the whole subsiding in a few days, with 
desquamation of the cuticle; even purpura, although with very doubt¬ 
ful correctness, has been ascribed to the alkaloid (Boston Med. and 
Surg. Journ., eix. 587). Chevallier describes (Gaz. des Hopitaux, 1850) a 
peculiar affection of the skin, etc., as occurring among workers in the 
bark. 

Local Use of Quinine. —The effect of quinine upon the lower organ¬ 
isms has suggested its local use in various disorders supposed to depend 
upon the presence of such entities. Thus, Dr. Henke (Deutsches Archiv 
fur Klin. Med., Bd. xii. p. 630), finding some peculiar motile cells in the 
sputa of whooping-cough , employed inhalations of quinine with asserted 
good results. Dr. Henke was not, however, the first to suggest either 
this fungoid pathology of whooping-cough or the use of quinine. Pro¬ 
fessor Binz in 1870 (Amer. Journ. Obstetrics and Diseases of Women, iii.) 
claimed that quinine bad a specific action in whooping-cough, provided 
it was given in large doses in solution, so as to come in contact with 
the mucous membrane in its passage through the pharynx; and in 
1871 Letzerich (Ibid., vol. iv. p. 761) announced that whooping-cough 
was due to a fungus in the lung. Professor Dawson (Ibid., 1873) has 
confirmed the value of the method of Professor Binz; but, if the fun¬ 
goid theory be—as I do not believe—true, the plan of Henke must 
certainly be the better one. The use in hay fever, as recommended 


A N TIPERIOD ICS. 


585 


by Helmholtz, of a weak tepid solution (gr. j to iii—f^i), as nearly 
neutral as possible, freely applied to the nasal mucous membrane, has 
not achieved general recognition, and any influence which the alkaloid 
has in either whooping-cough or hay fever probably depends upon its 
direct influence upon the mucous membranes. In the later stages of 
gonorrhoea the topical employment of its solution (gr. v to x—fgi) is 
often serviceable. 

Administration.— Owing to its bitter taste, sulphate of quinine is 
generally given in pill, which may be made with gum, or simply by 
adding a little sulphuric acid to the alkaloidal salt and quickly rubbing 
up the pasty mass into pills before it hardens. When a rapid action 
is desired, the quinine should be given in powder, or in solution made by 
adding a drop of dilute sulphuric acid for every grain of the salt. In 
the use of pills of quinine, care should be exercised to see that they 
are soft and fresh, for when old and hard they not unfrequently pass 
through the bowels unchanged. The ready-made “ sugar-coated” pills 
kept in the shops should be avoided, as uncertain in their action. The 
taste of the powder is best covered by chocolate or by liquorice. 

When sulphate of quinine is given hypodermically it acts with much 
greater promptness and apparently with greater force than when ad¬ 
ministered by the stomach. Albertoni and Ciotto {Bull. Therap., xc. 
403) found that when they injected it into the jugular vein it failed to 
appear in the bile, but when they administered it by the mouth it was 
freely eliminated with that secretion. Biliary salts of quinine are so 
insoluble that their reabsorption must be effected, if at all, very slowly: 
hence possibly the superior efficiency of the hypodermic method. The 
local irritant action of quinine, however, forbids its hypodermic employ¬ 
ment except in cases of great emergency. Given in this way, it very 
generally produces great local disturbance (abscesses, ulcers, etc.), and 
in several cases has caused fatal tetanus ( Lancet , 1876, i.). When it is 
so given, care should be taken to have an excess of acid (tartaric is the 
best) in the solution, to prevent precipitation of the quinine by the 
alkaline juices of the cellular tissue. The bisidphate of quinine (Quinines 
Bisulphas , U.S.) is soluble in ten parts of water, and should be preferred 
for hypodermic use: even its solution should be slightly acidulated. Ten 
grains of quinine injected under the skin are probably equivalent to 
fifteen grains given by the mouth. 

Contra-indication. —On account of its irritant properties, quinine must 
be used with caution when there is irritability or inflammation of any 
part of the gastro-intestinal tract. It is strongly contra-indicated by 
inflammation of the middle ear, and may greatly and permanently in¬ 
crease dulness of hearing. In connection with this the statement of 
Dr. M. Friedmann (Wien. Med. Presse, 1884, 927) that ergotin, given 
with quinine or salicylic acid, very much lessens the auditory disturb¬ 
ance, is of great interest. 

The hydrobrornate of quinine (Quinines Mydrobromas, U.S.) is soluble 


586 


GENERAL REMEDIES. 


in about sixteen parts of water and in three parts of alcohol. It is 
stated that a ten-per-cent, solution in a mixture of twenty-five parts of 
alcohol and seventy-five parts of water is not irritant when used hypo¬ 
dermically. 

The tannate of quinine ,* although not officinal, has been used to some 
extent, and is certainly not inefficient. It has the great advantage of 
not being disagreeable to the palate, but is less active and less certain 
than the more soluble salts of the alkaloid, and is also much slower in 
its operation. If given at all, it should be in doses one-third greater 
than those of the sulphate. 

The double bimuriate of quinine and urea, although not officinal, 
has been used to a considerable extent for hypodermic injections. It 
is said that a fifty-per-cent, watery solution, when thrown into the 
cellular tissue, produces very slight local irritation. It is also affirmed 
to contain about sixty-one per cent, of the alkaloid, and it is certainly 
capable of producing cinchonism. 

Quinidine Sulphas. U.S .—Sulphate of quinidine occurs in long, 
shining, silky, acicular crystals, soluble in one hundred and thirty 
parts of water at 62° F., in sixteen parts at 212°, readily soluble in 
alcohol, nearly insoluble in ether. It is a basic salt, like the sulphate 
of quinine, readily taking another equivalent of acid. It behaves like 
its isomer with chlorine and ammonia, but is distinguished by rotating 
light powerfully to the right, instead of moderately to the left. It 
probably closely resembles quinine in its physiological and therapeutic 
properties, and is an efficient antiperiodic: the dose is about one-third 
larger than that of quinine. 

Dextro-quinine, a brown, amorphous substance, derived from chinoi- 
dine, is said to answer all the tests for quinine except to polarize to the 
right. It is probably an impure quinidine. 

CINCHONINE SULPHAS—SULPHATE OF CINCHONINE. U.S. 

The pure alkaloid cinchonine crystallizes in prisms and needles. 
The officinal sidphate of cinchonine is in short oblique prisms of a very 
bitter taste, soluble in fifty-four parts of water, more freely in boiling 
water, readily soluble in alcohol. From its solution in chlorine-water 
it is precipitated white by ammonia. Bill’s test for it consists in adding 
the ferrocyanide of potassium in slight excess to its solution. A yel¬ 
lowish-white curdy precipitate is the result. On gently heating, this 
redissolves, but is again deposited, when the liquid cools, as abundant 
golden-yellow crystals. 

Physiological Action.— Conzen (quoted by Husemann) has found 
that the action of cinchonine on infusoria and on fermentation is similar 
to but weaker than that of its sister alkaloid, and that on the movements 


* For an elaborate discussion of the therapeutic value of this salt, see Bulletin de 
I’AcadSmie, Paris, 1872. 




ANTIPERIODICS. 


587 


of the white blood-corpuscles its influence seems transient. Laborde 
states that pure quinine does not cause epileptiform convulsions in the 
lower animals, although commercial quinine does so on account of its im¬ 
purity, and that in poisoning with cinchonine violent epileptiform con¬ 
vulsions arc a chief symptom ( Compt.-Rend. Soc. Biolog. , iv. 1882). M. 
Bochefontaine ( Compt.-Rend. Acad. Sci., t. xcvi. p. 503) affirms, however, 
that quinine does convulse, although less actively than does cinchonine, 
which latter alkaloid he found to vomit less than quinine. According 
to Johnnsen, the effect of cinchonine upon the elimination of urinary 
solids is even more powerful than that of quinine. It is eliminated un¬ 
changed, appearing in the urine in half an hour, and disappearing after 
massive doses only in ninety-six hours,—the great bulk being thrown 
off in the first twenty-four hours ( Pflanzenstojfe , p. 1480). In Bochefon- 
taine’s experiments the relative strength of cinchonine to quinine was 
about 10 to 16 ( Ibid ., p. 506); in Bernatzik’s (on dogs only) as 4 to 5. 

Therapeutics. —As an antiperiodic, cinchonine exerts a similar in¬ 
fluence to quinia, but is probably about one-third weaker than that 
alkaloid, and must be used in correspondingly larger dose. Dr. J. B. 
Hamilton ( loc. cit .) affirms as the result of experiment that cinchonine 
as a prophylactic against malaria is even superior to quinine. As a 
tonic 1 have never been able to perceive that cinchonine acts differently 
from quinine. 

Cinchonidine Sulphas. U.S. —Sulphate of cinchonidine occurs in 
white, silky, lustrous needles or prisms, odorless, of a very bitter taste, 
soluble in 100 parts of water, freely soluble in acidulated solutions. It 
polarizes to the left, and is not fluorescent. Gr. See and M. Bochefon¬ 
taine found that the lethal dose of cinchonidine for the frog is 0.015 
gramme; for the dog, 2.50 grammes. The symptoms in the dog are 
general feebleness, titubation, inci’ease of pulse-rate and arterial press¬ 
ure, vomiting, salivation, convulsions,—less severe than those caused 
by quinine,—great loss of muscular power, stupor, fall of arterial press¬ 
ure and of temperature, death from arrest of respiration ( [La France 
Med., 1883, 527). A boy aged five years took one hundred and twenty- 
eight grains in solution during six hours without vomiting. There 
were then convulsions, followed by great collapse, fall of temperature, 
pulselessness (with seventy-four cardiac beats per minute), dilated 
pupils, muscular relaxation, and, finally, death; consciousness was 
preserved to the end ( N. Y. Med. Journ., xxxix. 1884). It is evident 
that this alkaloid closely resembles its congeneric alkaloids in its action 
upon the human organism. Clinical experience has proved it to be a 
reliable tonic and antiperiodic. According to Byasson, it is eliminated 
by the kidneys unchanged. It has been claimed that it produces less 
disagreeable symptoms, both gastric and cerebral, than does quinine; 
but Dr. Rafferty, who has administered three hundred ounces of the 
sulphate, affirms that it is more apt to cause nausea and vomiting. 


588 


GENERAL REMEDIES. 


The dose is one-third greater than that of quinine. Dr. De Segrais has 
found the bromohydrate given hypodermically in doses of 4 to 6 grains 
very efficacious (Arch. Generates , xvii. 711). 

Chinoidinum. U.S.— Chinoidin , or Quinoidin, is a blackish sub¬ 
stance, with an almost resinous fracture, which is obtained by the 
evaporation of the mother-liquor after the crystallization of the alka¬ 
loids out of it. This substance contains probably amorphous quinine 
and cinchonine, besides quinidine and cinchonidine. It is an excellent 
tonic and antiperiodic, and, on account of its cheapness, is lai’gely used 
in some of the eleemosynary institutions of this city. It should be 
administered in about double the dose of quinine, and is most efficient 
in solution, but, on account of its taste, is often given in pills. Its solu¬ 
tion should be made with acetic acid and water, aromatics being freely 
added, as it is apt to cause nausea. 

The U.S. Pharmacopoeia recognizes for use as a tonic an infusion of 
bark (Infusum Cinchonce —1 to 16.6), dose, a wineglassful; a tincture of 
the yellow bark ( Tinctura Cinchonce —1 to 5), dose, one to two teaspoon¬ 
fuls; a compound tincture (Tinctura Cinchonce Composita — Huxham's 
Tincture ), which, as a tonic, is the best preparation of the bark, and is 
a very elegant remedy in convalescence, in doses of one teaspoonful to 
a tablespoonful; also a fluid extract and a solid extract (Extractum 
Cinchonce Fluidum and Extractum Cinchonce'), the doses of which are 
five to fifteen drops or grains respectively. 

Cinchonamine.— This alkaloid was discovered by Arnaud (Compt.- 
Jtend., vol. xciii.) in the Cuprea bark from Colombia, probably the prod¬ 
uct of Remijia pedunculata and Remijia Purdieana. Its physiological 
action has been partially investigated by See and Bochefontaine (Compt.- 
Rend., vol. c.). In poisonous doses it produces violent convulsions in 
the dog, with fall of the arterial pressure. It also arrests the heart in 
diastole, and increases especially the secretion of the salivary glands. 
Its influence upon man has not, so far as I am aware, been studied, but 
its botanical and chemical relations make it probable that it resembles 
quinine in its physiological and therapeutical properties. 

Warburg’s Tincture. —This is a dark-brown liquid, prepared in 
accordance with a very complicated formula,* which has obtained an 
extraordinary reputation in India and other tropical countries in the 
treatment of severe remittent and malignant malarial fevers. The testi¬ 
mony is so strong as to its remarkable and almost certain efficiency 
that it cannot be questioned, and entitles the tincture to rank above 
all other'remedies. The method of administration is as follows. The 


* For formula, see Med. Times and Gaz., 1875, ii. 541; or Phila. Med. Times, vi. 136; or 
London Practitioner, xviii. 82. 



A N TIPERIODICS. 


589 


bowels having been freely opened, a half-ounce of the tincture is given 
undiluted, all drink being withheld, and at the end of three hours a 
second half-ounce is in similar manner exhibited. Soon after the last 
dose a profuse and very aromatic perspiration sets in, and convalescence 
is usually secured. The remedy is also commended in one-drachm dose 
in acute nervous exhaustion and collapse without organic disease. 

EUCALYPTUS. U.S. 

The Eucalyptus globulus* is a large tree, native of Australia. The 
leaves, which are alone officinal, contain, besides tannic acid, a volatile 
oil, which, when pure, is nearly colorless, of a warm, mint-like taste, 
with a bitter after-taste, and a peculiar mint-like odor. This oil is freely 
soluble in ether, alcohol, and the fatty oils, and is obtained by distilla¬ 
tion or by acting on the leaves with ether. It does not undergo oxida¬ 
tion into a resinous mass on exposure to the air, and is remarkable for 
its power of resisting the influence of concentrated sulphuric acid. It 
has been affirmed that the leaves of Eucalyptus contain also an alka¬ 
loid ; but Rabuteau {Bull. Therap., lxxxiii. 549) has demonstrated that 
this is an error. All the virtues of the remedy probably reside in the 
volatile oil, which is in greatest abundance in the leaves. According 
to the researches of Stanislas Martin {Bull. Therap ., lxxxiii. 453), the oil 
is entirely absent from the bark of plants grown in Southern France 
and Corsica, but exists in that from Australia and Algeria. 

Physiological Action.— Locally, the oil of Eucalyptus acts as a 
decided but not very intense irritant, and the first effect of large doses 
is burning in the mouth and fauces, with increased secretion of saliva, 
followed very soon by a feeling of warmth in the stomach. 


* Attention was first called by Labillardiere in 1792 to the value of the Eucalyptus glob¬ 
ulus, but it was not until 1860 that M. Ramel commenced the culture of the tree in Paris and 
induced the Prefect of the Seine to order its cultivation on a large scale. Since that time it 
has been largely introduced into Europe, Algeria, South Africa, and California, and in some 
of these countries planted forests are now growing and spreading. The tree is remarkable 
for combining extreme hardness of wood with a rapidity of growth asserted to be about five 
times that of our ordinary trees; it is even affirmed that shingles made of it are fire-proof. 
Its capability for absorbing and evaporating water is extraordinary, and to it has been at¬ 
tributed the freedom of Australia from malarial climatic influences. Indeed, it is stated 
that a tree will evaporate ten times its weight of water in twenty-four hours, and numerous 
examples are given in which swamps in Europe and Algeria have been rapidly converted by 
it into dry ground. It is believed to destroy malaria not only by draining the soil, but also 
by yielding balsamic exudations to the air: however this may be, there is at present very 
strong evidence as to its power of rendering infected districts healthy. As, however, the con¬ 
sideration of this belongs to the subject of hygiene rather than of therapeutics, the reader is 
referred for detailed information to the following memoirs: Regulus Carlotti, L’Eucalyptus, 
son Rang parmi les Agents de la Matiire Medicals, Ajaccio, 1872; M. Gimbert, L’Eucalyptus 
Globulus, son Importance eti Agriculture, en Hygiine et en MSdecine, Paris, 1870; Waterer, 
Bulletin de la SociStS d’Acclimatation, 1872; London Medical Record, Dec. 1873; London 
Lancet, ii., 1877. 

Under the name of Eucalypsinthe, a liquor distilled from the leaves of the Eucalyptus 
has appeared in European commerce. 



590 


GENERAL REMEDIES. 


The general effect of the same dose of the oil appears to vary con¬ 
siderably in different individuals; but the following summary comprises 
the facts as nearly as may be. After the ingestion of from ten to 
twenty drops, a period of mental and physical activity is often ap¬ 
parent, followed by a feeling of calm and serenity. By larger doses, 
or in susceptible persons by the doses mentioned, there is caused in¬ 
creased disturbance of the digestive organs, ending often in loose stools 
having the odor of the oil, with augmentation in the frequency and 
force of the pulse. Gubler adds to these symptoms an increase of 
temperature; but in Gimbert’s experience febrile manifestations, al¬ 
though occasionally occurring, were not usually present. In some cases 
the medicine acts very disagreeably, producing violent cardiac palpita¬ 
tions or intense headache: how far these are directly dependent upon 
the drug, or are sympathetic upon its local action on the stomach, is 
uncertain. If the dose be repeated, or if a larger amount be taken at 
once, a period of sedation manifests itself; the pulse loses its force, and 
the animal temperature is abated. After doses of seventy-five grains, 
Binz noted numbness of the limbs, with a feeling of excessive weight 
in them. If the use of the remedy be persisted in, a state of asthenia 
is induced; the temperature falls as much as a degree and a half, and 
the pulse even to fifty (Gimbert, Archives Generates, 1873, xxi. 141); 
the respiration becomes less frequent, and the muscular weakness ex¬ 
treme, so that raising the arm to the mouth is painful; the sensations 
are blunted, but the intellect is absolutely unaffected. In an old man 
who took eighty drops, the power of motion almost disappeared, and he 
affirmed that he lost for the time being all sense of the presence of his 
limbs, so that he was unconscious of possessing them when he shut his 
eyes, although his intellect was perfectly clear throughout. 

Upon the lower mammalia the oil of Eucalyptus appears to act 
precisely as it does on man. According to the experiments of Gimbert, 
the hypodermic injection of the oil is immediately followed by a period 
of excitement, seemingly in great measure due to the intense local irri¬ 
tation ; after about half an hour, if the dose has been sufficiently large, 
the animal begins to stumble and totter in walking, the breathing grows 
more and more slow and irregular, the limbs give way, the ears droop, 
the muscular weakness becomes profound, and death, preceded often 
by partial convulsions, occurs through failure of respiration. In Gim¬ 
bert’s experiments the heart always continues to beat after breathing 
had ceased. As the motor nerves and the muscles retained their func¬ 
tional power after death, the failure of motility and reflex activity must 
have been central, and Gimbert concludes that the drug in toxic doses 
is therefore a -paralyzant to the spinal cord and the medulla. This 
conclusion was also attained experimentally by Binz ( British Medical 
Journal , i., 1874). Various observers accord in stating that after toxic 
doses there is, in animals, a decided fall of temperature. It would 
appear from the experiments of Hermann Schlager that after hypo- 


A N TIPERI ODICS. 


591 


dermic injections the temperature sometimes rises, probably as the 
result of the local irritation ( Die Physiol. Wirk. d. Eucal. glob., Inaug. 
Diss., Gdttingen, 1874). The same observer noted that the arterial 
pressure was greatly lessened. As this fall occurred after paralysis of 
the par vagum by section or by atropine, and also after vaso-motor 
paralysis by section of the cord, it must be due to a direct action upon 
the heart. This was confirmed by the direct influence of the drug 
upon the cut-out heart of the frog. The oil is probably eliminated by 
the lungs, skin, and kidneys. In the experiments of Professor Binz, 
the day after the ingestion of seventy-five drops the breath smelt of 
the drug, and the perspiration of amylic alcohol. The urine began to 
have the odor of the oil an hour and a half after its ingestion, and 
continued to have it for thirty-six hours. Dr. Gimbert states that the 
odor imparted to the urine resembles that of violets, and is very similar 
to that caused by turpentine. 

Binz states that upon the lower infusoria the oil acts even more power¬ 
fully than does quinia; and its antiseptic properties are without doubt 
very great (Gimbert, Archives Generates, xxi. 137). Mosler ( Deutsches 
Archiv f. Klin. Med., 1872, x. 160) affirms that in dogs whose spleens 
were exposed, injections of tincture of the leaves of Eucalyptus pro¬ 
duced a decided contraction of the viscus. According to Gimbert, the 
excretion of urea is enormously increased by the use of the drug. 

Therapeutics. —The chief use that has been made of Eucalyptus is 
as an antiperiodic. So far as I know, Dr. Joseph Keller ( Wiener Medi- 
zinische Wochenschrift, xxii., 1872) has employed it upon a larger scale 
than any one else. He used it in four hundred and thirty-two cases, 
of which two hundred and ninety-three had suffered from previous 
attacks. Of the tertians 75.57 per cent., of the quartans 70 per cent., 
and of the quotidians 67.89 per cent, yielded to the remedy. He rec¬ 
ommends it as especially valuable in obstinate cases in which quinine 
has been taken again and again. Lorinser ( Wiener Medizin. Wochen¬ 
schrift, xix., xx.), Haller ( Wiener Medizin. Wochenblatt, xxvi.), Bohn 
(Berlin. Klin. Wochenschrift , 1872), Carlotti ( loc. cit .), Cortan ( Mont¬ 
pellier Medical, May, 1872), Gimbert (loc. cit.), Gubler (loc. cit.), Tristany, 
of Spain (Buchner's Repertoriurn, xix., 1870), J. H. Musser (Therap. 
Gaz., 1886, 369), and others, bear testimony to the value of Eucalyptus 
in malarial diseases; while Brudell ( Bulletin Therapeutique, May, 1875), 
Seitz (Bayer. Aerztl. Intell. Blatt, 1870), and Papillon (Gazette Hebdoma- 
daire, 1872) affirm it to be of little or no value. The weight of testi¬ 
mony is in favor of the possession of decided antiperiodic powers by 
Eucalyptus, and where the cinchona alkaloids have failed, or for any 
reason cannot be taken, it ought to be tried. Oil of Eucalyptus is also 
one of the best stimulating expectorants that we possess: in both acute 
and chronic bronchitis it may be exhibited when there is free secretion. 
I have found that children bear it very well in proportionally large doses. 
From one-half to one drachm a day may be given, in divided doses. 


592 


GENERAL REMEDIES. 


ACIDUM PICRUM—PICRIC ACID * 

Picric or Carbazotic Acid is not officinal, but has been used to some 
extent in medicine. It occurs in pale-yellow, shining scales, but is 
employed by the therapeutist only in the form of a salt, on account of 
the deleterious influence of the pure acid on the gastric mucous mem¬ 
brane: the picrate of potassium, of sodium, or of ammonium may be 
used; but the last is the one generally chosen. 

Physiological Action.— The only detailed study of picric acid 
known to me is that of Dr. W. Erb (Die Pikrinsaure, Wurzburg, 1865). 
This observer found that the daily use of a grain (for ninety days) of 
a picrate produced, in a rabbit, yellowness of the conjunctiva, of the 
inner surface of the ear, and of the urine, with an occasional slight 
diarrhoea and great loss of weight, without any elevation of tempera¬ 
ture. After a time the animal seemed to grow accustomed to the 
remedy, so as to regain in great measure its flesh. Three grains a day 
caused, in about two weeks, the death of the rabbit, with symptoms of 
inanition. All the tissues, except the nervous, were stained of an in¬ 
tense reddish-yellow color, as was also the urine. Eight grains jiro- 
duced falling temperature, weakness, diarrhoea, collapse, and death, 
sometimes preceded by tremblings and even by convulsions, in about 
twenty-three hours. Most of the tissues were stained yellowish red. 
The most remarkable physiological effect of the poison occurred in the 
blood. The blood of animals slowly killed by a picrate was of a dirty- 
brown color, with distinct nuclei both in the red blood-disks and float¬ 
ing free in the serum. Dr. Erb found that this alteration in the cor¬ 
puscles occurred during life and was accompanied by a decided increase 
in the number of the white corpuscles. These alterations in the blood 
were apparently the cause of death, and seem to have been due, so far 
at least as concerned the red disks, to a direct action of the poison upon 
the blood; for Erb found that identical or very similar alterations oc¬ 
curred in these corpuscles when the blood was mixed with the picrate 
of sodium outside of the body. 

Erb found picric acid to act on man as on the lower animals. 
Twenty-four hours after the ingestion of fifteen grains of it the yellow 
color was very plain in the conjunctiva, the skin, and the urine. The 
temperature was not elevated, and gastric disturbance was usually 
absent, but sometimes it was severe. As in animals, so in man, picric 
acid was found abundantly in the urine. A teaspoonful produced no 
more violent symptoms in a man than bad vomiting and purging 
(Wiener Med. Presse, xxiii. 1526). 

Professor Binz ( Virchow’s Archiv, Bd. xlvi. p. 130) has found that 


* Picric acid scarcely belongs in this chapter, but, as it has attracted most attention as an 
antiperiodic, in the ignorance which exists as to its physiological action I have here intro¬ 
duced it. 



ANTI PERIOD ICS. 593 

picric acid exerts upon the infusoria an influence similar to, but much 
feebler than, that of quinia. 

Therapeutics. —The carbazotate of ammonium has been strongly 
recommended by various authorities in malarial disorders; but in the 
experiments of Erb the result was so negative that the possession of 
any antiperiodic powers by the drug is doubtful,* although Mr. H. M. 
Clark ( Lancet , i. 1887) affirms that he has treated with it ten thousand 
cases of malarial disease with such good results that he has abandoned 
the use of the cinchona alkaloids. He gives from one-eighth to one- 
half grain four times a day in pill,—one-third of a grain being the 
average dose. As an anthelmintic , the picrate has also been commended; 
but Erb found it powerless in cases of taenia , and for the destruction 
of the round-worm and thread-worm there is an abundance of safer 
and even more efficient remedies. A matter of the gravest importance 
is the asserted efficiency of the remedy in trichiniasis. Erb has pro¬ 
duced slow poisoning with a picrate in rabbits which had been fed 
upon affected meat, and, on examining their bodies after death, found 
the trichina everywhere, even in the walls of the intestines, in very 
active life. On the whole, the testimony so far seems to indicate that 
picric acid has no value as a therapeutic agent. Erb states that in 
robust adults from nine to fifteen grains a day may be given for a long 
time with safety; but I should fear the effects of more than half that 
quantity. 


* Consult Deutsche Klinik, 1855, No. 40; Med. Times and Gaz., Sept. 1862; New Reme¬ 
dies, 1873; Gazette des Hopitaux, xlv. 116; Ohio Med. Recorder, 1877. 


38 




FAMILY Y—ANTIPYRETICS. 


ACIDUM CARBOLICUM—CARBOLIC ACID. U.S. 

Phenic Acid , Phenylic Alcohol , is a substance obtained from coal-tar 
by distilling at a temperature of between 300° and 400° F., adding to 
the distillate a hot concentrated solution of potassa, and, after this, 
water, separating the light oily matters which rise to the top, and 
adding muriatic acid to the heavy alkaline bottom layer, when impure 
carbolic acid separates. This impure carbolic acid ( Acidum Carbolicum 
Crudum , U.S.) is of a dark color, and contains several congeneric bodies, 
especially xylic and cresylic acids. For disinfectant purposes these 
appear to be at least of equal value with the carbolic acid, and there¬ 
fore the crude product of the above-detailed process is very largely 
used. Carbolic acid is separated from its allies and obtained in a pure 
state with some difficulty, by a process too complex to be discussed 
here. When finally procured, it occurs at ordinary temperatures in 
minute, colorless, transparent plates, or long rhomboidal needles, often 
fused into a mass, having a hot, corrosive, peculiar taste and a peculiar 
odor, resembling but decidedly different from that of creasote. If, on 
exposure to the air, phenic acid becomes brown, it contains impurities. 
When opportunity is afforded, solid carbolic acid absorbs water from 
the atmosphere and melts into an oily-looking, colorless liquid. It is 
inflammable, neutral to test-paper, but combines with bases; soluble in 
about twenty parts of water, very soluble in alcohol, acetic acid, ether, 
glycerin, and the volatile and fixed oils. Nitric acid converts it into 
picric acid. 

Physiological Action.— Carbolic acid is exceedingly poisonous to 
all forms of life, from the lowest to the highest. Much of its employ¬ 
ment in medicine depends upon its action on infusoria and fungi; and 
yet its direct internal and external use in human medicine is quite 
large. Its physiological action is therefore to be viewed from two dis¬ 
tinct stand-points: first, its influence upon the higher animals and man; 
secondly, its action on the lowest animal and vegetable forms. 

According to Dr. Isidor Neumann ( Archiv f. Dermatol, u. Syphilog., 
Jahrgang i., 1869, p. 425), to Dr. Ernest Labee ( Archives Gen., 6e ser., 
t. xviii. p. 451, 1871), and to Salkowski ( Pfliiger's Archiv , Bd. v., 1872), 
when a poisonous dose of carbolic acid is given to a frog there is pro- 
594 



ANTIPYRETICS. 


595 


duced a paralytic condition which usually affects first the hind legs,* but 
eventually spreads to the front legs and involves all parts of the body. 
After a time there are developed tetanic convulsions, which are appa¬ 
rently reflex in their nature, and are said to be excited by external 
stimuli or irritations. 

Carbolic acid acts upon mammals in very much the same way as 
upon the batrachian. According to W. Kempster ( Amer. Journ. Med. 
Sci., July, 1868), in the mouse and rat it causes intense muscular weak¬ 
ness, followed by violent convulsions and stupor. In the rabbit (Neu¬ 
mann, Salkowski), phenylic alcohol produces muscular weakness, often 
accompanied by tremblings and restlessness, at last giving place to vio¬ 
lent convulsions. Before these have fairly set in, the animal is gen¬ 
erally unable to stand ; and during them he lies on his side, kicking into 
mid-air. Early in the poisoning the respiration is very much affected ; 
and the death, which usually occurs in the midst of convulsions, appears 
to be owing to a paralysis of the respiration , since in acute cases the 
heart is found beating continuously immediately after death. Accord¬ 
ing to the researches of Dr. Jules Lemaire ( De VAcide Phenique , 2d ed., 
Paris, 1865), in the dog symptoms very similar to those detailed above 
are caused by lethal doses of the drug; and IJusemann ( Schmidt's Jahrb ., 
Bd. civ. p. 274) states that in mammals and in birds the characteristic 
phenomena of carbolic acid poisoning are clonic convulsions, sinking 
of the temperature, diminution of sensibility, dyspnoea, free salivation 
and secretion of tears, keratitis, and conjunctivitis. According to the 
latter authority, albuminuria and htematuria are occasional phenomena. 
Upou man carbolic acid acts as upon other mammals. Reserving the 
details for the section on Toxicology, it is sufficient for our present pur¬ 
pose to state that the prominent symptoms induced by lethal doses are 
disturbance of respiration, coma, muscular weakness, and, in some cases, 
convulsions. A closer investigation of the action of large doses of car¬ 
bolic acid is best made by studying the effects upon the different systems 
seriatim. 

Nervous System. —Upon the cerebrum phenylic alcohol appears to 
exert a direct influence, which, although not very intense in the lower 
animals, in the higher species, and especially in man, results in the 
early production of stupor. 

The convulsions are not peripheral, since they do not occur in a 
limb whose connection with the spine has been severed by division of 
the nerve, and do take place in a leg which has been protected against 
the local action of the poison by tying the artery (Salkowski, Labee). 
They are, therefore, either cerebral or spinal. Although there is a dis¬ 
tinct conflict of evidence, it seems to me established that they are of 
spinal origin. Labee and J. R. Haynes failed to get them after sec- 


* According to Lemaire, when a frog is allowed to swim in water impregnated with car¬ 
bolic acid, the front legs are the first affected. 



596 


GENERAL REMEDIES. 


tion of the cord, but in the far more numerous experiments, upon frogs 
and mammals, of Salkowski, of Berb and Jogel ( Gaz. Med., 1872), of 
J. S. Stone ( Phila. Med. Times, ix.), and of T. Gies {Arch. f. Exper. 
Path. u. Pharm., xii. 401), convulsions occurred after destruction of 
the medulla, section of the cord, and other operative procedures sepa¬ 
rating the brain from the lower nervous system. The failures of the 
first-named experiments are explainable by the facts that the paralyzing 
influences of carbolic acid are usually first manifested upon the hind 
legs, and that very large doses of the acid were employed. The spinal 
convulsions are accompanied by increased reflex activity, which is lost 
as the paralytic state is reached, so that carbolic acid appears first to 
stimulate and then depress the spinal centres. Stone asserts that the 
stimulation is preceded by a primary depression, due to stimulation of 
Setschenow’s inhibitory centre in the medulla. 

In carbolic acid poisoning the nerves and muscles are not distinctly 
paralyzed, galvanic stimulation of a nerve after death eliciting vigor¬ 
ous response in the tributary muscle (Salkowski, loc. cit., p. 338; Hoppe- 
Seyler, loc. cit., p. 476); but the very careful experiments of Gies (loc. cit., 
p. 413) have proved that such muscles are less sensitive and more easily 
exhausted than in the unpoisoned animal. 

Circulation .—The action of carbolic acid upon the heart is not a 
very marked one, but there can be little doubt that in sufficient amount 
the drug depresses the heart. After death from acute poisoning the 
heart is usually found to be beating regularly (Salkowski), but in some 
cases of slow poisoning the death has seemed to be ultimately caused 
by cardiac diastolic arrest. In Hoppe-Seyler’s manometrieal studies 
(Pfiuger's Archiv, 1872, v. 475) the arterial pressure was not affected 
untd convulsions came on, when it rose from the effects of the general 
muscular contraction. It afterwards fell very decidedly, and perma¬ 
nently. Beduction of the arterial pressure has been shown by Gies to 
be the characteristic effect of the carbolic acid: in his experiments 
moderate doses of the acid failed to affect the pressure after section of 
the cord, whilst in the normal animal neither asphyxia nor stimula¬ 
tion of a sensitive nerve elevated the lowered pressure, although the 
heart was beating forcibly,—facts that demonstrate that carbolic acid 
paralyzes the vaso-motor centre in the medulla before it markedly affects 
the heart. 

Respiration .—According to Salkowski (loc. cit., p. 344), Labee, and 
other authorities, in the first stages of carbolic acid poisoning the respi¬ 
ration is remarkably increased in frequency. This acceleration Sal¬ 
kowski believes to be due partly to a stimulant action upon the 
peripheral vagi, and partly to a similar influence upon the respiratory 
centres. He states that the respirations are very shallow, and that the 
diaphragm scarcely participates at all in them, but that if the cervical 
vagi be cut they become much slower, deep, and regular. On the other 
hand, if carbolic acid be given to an animal suffering from section of 


ANTIPYRETICS. 


597 


the pneumogastrics, the slow breathing is very much accelerated. 
From the former of these facts the German investigator draws the con- 
elusion that the accelerated breathing produced by phenylic alcohol is in 
part due to a stimulation of the peripheral vagi, and from the latter fact 
that it partly arises from a similar action upon the respiratory centres. 

Temperature .—According to the researches of Dr. Hobart A. Hare 
( Therap . Gaz., 1887, 519), carbolic acid injected into rabbits produces a 
very distinct fall in the bodily temperature, which is usually but not 
always coincident with the lowering of the arterial pressure. In the 
calorimetric studies made by Dr. Hare the effect upon heat-production 
and heat-dissipation in the normal animal appeared to be various, some¬ 
times production and sometimes dissipation being alone affected, while 
in other cases both functions were altered. Some years ago, Emil Erls 
(. Schmidt's Jahrbucher, Bd. clxiv. p. 148) found that in mild putrid poi¬ 
soning in animals carbolic acid diminished greatly the fever-heat; when 
the poisoning was more severe it had no influence. The calorimetric 
studies made by Dr. Hare upon fevered animals were fairly constant 
in their results, although the method of experimentation was not 
satisfactory, because the acid was given to the fevered animals at a time 
when it was uncertain what would have been the production of heat 
without its influences (see foot-note, p. 627.) Nevertheless the experi¬ 
ments indicate that carbolic acid may affect the thermogenetic func¬ 
tions of the body in two ways: first, by diminishing the production 
of heat; secondly, by increasing the dissipation of heat. 

In sufficient concentration carbolic acid seems to be poisonous to all 
forms of protoplasm. Dr. T. M. Prudden ( Amer. Journ. Med. Sci., 
lxxxi. 82) finds that in strong solution it paralyzes, in weak solution de¬ 
presses, the movements of the batrachian white blood-corpuscles and 
ciliated cells; and Labee has determined that outside of the body it 
materially affects the blood of mammals. Both Labee and Iloppe- 
Seyler ( Pfluger's Archiv, v. 476), however, affirm that the blood of 
higher animals poisoned by carbolic acid presents nothing abnormal: so 
that the symptoms it produces must bo the result of a direct influence 
upon the various tissues. 

Post-mortem examinations of animals killed by carbolic acid have 
yielded varying results. In Lemairc’s investigation, nothing abnormal 
was found except intense injection of the alimentary mucous mem¬ 
brane, a pseudo-membranous and purulent inflammation of the bron¬ 
chial tubes, with a disseminated lobular pneumonia or else congestion 
of the lungs and of the nerve-centres. Professor Bruckmuller, in Neu¬ 
mann’s investigation (loc. cit ., p. 429), found the cells of the liver and 
kidneys in a state of fatty degeneration. This process, which seem¬ 
ingly was the counterpart of the changes in phosphorus-poisoning, was 
always more advanced in the kidneys than in the liver. Dr. Neumann 
states that it was always present in his numerous autopsies, and that it 
is a constant phenomenon; but Salkowski {loc. cit., p. 273) was unable to 


598 


GENERAL REMEDIES. 


find it in a number of examinations. In man, the post-mortem appear¬ 
ances are very much the same as in animals. If the acid has been 
ingested in a concentrated form, white, hardened spots are found upon 
the mucous membrane of the mouth, oesophagus, stomach, and even 
intestines. They are, of course, due to the local action of the poison, 
and are sometimes blackish in the centre, or even blackish throughout, 
and very generally are surrounded by a red inflammatory zone. The 
liver, spleen, kidneys, and indeed all the organs, are found filled with 
dark, imperfectly-coagulated blood, such as is habitually found after 
death from asphyxia. According to Husemann, the fatty degeneration 
of the liver and kidneys is not either in man or in animals a constant 
or characteristic phenomenon of carbolic acid poisoning. Reuder 
found the renal epithelium degenerated in a man who had been fatally 
poisoned by the drug ( Journ. de Pharm. et de Chirn., p. 456, Dec. 1871). 

As the internal use of carbolic acid in such diseases as gangrene of 
the lungs is so closely connected with the question of its chemical his¬ 
tory in the system and its elimination from the body, the latter is of 
very great interest. Since carbolic acid coagulates albumen, its absorp¬ 
tion unchanged into the blood would seem a matter of doubt: yet in 
some form or other it certainly is absorbed, as is proved by the history 
of its elimination and by its having been found in the blood (Hoppe- 
Seyler, Pfluger's Archiv, Bd. v. p. 479). In exactly what form it circu¬ 
lates in the blood is not known; but most probably it is as an alkaline 
carbolate. Lemaire (loc. cit., p. 77) states that it may be found in the 
breath of poisoned animals ; but Hoffmann asserts that it is burnt up 
in the system, because he failed to detect it in any of the secretions. 
In this conclusion he is, however, certainly in error; for it has been 
distinctly proved that carbolic acid is rapidly eliminated from the sys¬ 
tem. It has been detected in the urine by Almen (Zeitschrift f. Analyt. 
Chimie, Bd. x. Heft vii.), by Patrouillard (Journal de Pharmacie et de 
Chimie , Dec. 1871, p. 459), by Salkowski ( Pfluger's Archiv, Bd. v.), by 
Hoppe-Seyler (loc. cit.), by Waldenstrom ( Zeitschr. des Allgemein. Apo- 
thek.-Vereines, Jan. 10, 1872), and by Hauxmann ( Ibid .); and Hoppe- 
Seyler (loc. cit., p. 480) has detected it in the saliva. It is probably 
eliminated in all the secretions. The researches of Baumann ( Zeitschr . 
/. Physiol. Chem. 1878, 350), which have been substantially confirmed, 
show that the carbolic acid is changed into a peculiar sulphocarbolic 
acid, a sort of ether-sulph-acid, having the formula C 6 H 6 0.S0 2 .0H, 
which finally unites with potash and is eliminated as a sulphocarbo- 
late; when large quantities of the acid are administered, some of 
it escapes unchanged, for in a fatal case of poisoning Patrouillard 
(Zeitschr. des Allgemein. Apothek.-Vereines, p. 460) obtained an oily fluid, 
believed to be pure carbolic acid, by shaking the urine with ether, allow¬ 
ing the mixed fluids to separate, and removing the ethereal layer and 
evaporating. 

Although, as stated, carbolic acid is to some extent eliminated from 


ANTIPYRETICS. 


599 


the system, a portion of it is burnt up in the body. The black coloring- 
matter of the characteristic urine of carbolic acid poisoning is in ail 
probability an educt from carbolic acid, formed by its partial oxidation. 
Hauxmann has proved that it is not altered haematin or any fixed 
coloring principle, by finding that the urine is cleared up by heating 
after the addition of an acid; and his conclusion is corroborated by 
the observation of Dr. Stevenson, of Guy’s Hospital {Brit. Med. Journ., 
April, 1870), who found that the black urine does not contain more 
than a normal proportion of iron. When carbolic acid is oxidized 
outside of the body, as by the action of permanganate of potassium, 
oxalic acid is formed ; and Salkowski has found that when phenic acid 
is given to animals oxalic acid appears in the urine. Other observers 
have, however, failed to find these oxalates. Fr. Schaffer {Journ. f. 
Prakt. Chem., xviii. 282), A. Uerbach ( Virchow's Archiv, lxxvii. 226), 
and E. Baumann and C. Preusse {Zeitschr. f. Physiol. Chem., iii. 156) 
found that the phenol was at least in part oxidized into liydrochinon, 
and partly into a greenish-black substance upon which the coloring of 
the urine seems to depend. The researches of L. Bi'ieger {Zeitschr. f. 
Klin. Med., 1881, ii. 25) led him to the conclusion that when carbolic acid 
is taken in not too large quantities a portion of it unites with sulphuric 
acid, and a portion of it is converted into various colored oxidation 
products, some of which are very poisonous. According to the experi¬ 
ments of W. Kochs, this change occurs in the largo abdominal glandular 
viscera {Arch. f. Physiol., xx. 64, xxiii.). Schmiedeberg has recently 
come to the conclusion that no phenol is oxidized in the body, but that 
it is all eliminated in combination with sulphuric acid, or to a less 
extent with glyco-uronic acid {Arch. f. Exper. Path. u. Therap., xiv. 288). 
The evidence is, however, too strong against this view, and tho true 
conclusion seems to be that when carbolic acid is taken in great excess 
it is in part eliminated as carbolic acid, and that the remainder of it (the 
whole of it when taken in moderate amount) in part escapes in combi¬ 
nation with an alkali as sulpho-carbolic and glyco-uronic acids and is in 
part oxidized in the system. (See also page 605.) 

Stadeler {Ann. d. Chem. und Pharm., Bd. lxxvii. p. 17) discovered 
that when sulphuric acid was freely added to cow’s urine the latter 
yielded upon distillation carbolic acid, and concluded therefrom that 
normal urine contains carbolic acid. He has been corroborated by 
Buliginsky {Hoppe-Seyler's Med.-Chem. Untersuch., p. 234) and by 
Hoppe-Seyler {Pfluger's Archiv, 1872, Bd. v. p. 470), and phenol is cer¬ 
tainly a constituent not only of the urine of cattle, but also of that of 
men, dogs, horses, and probably other animals. Baumann has suc¬ 
ceeded in producing carbolic acid out of fibrin by a protracted diges¬ 
tion with the pancreatic glandular substance, and Nencki and Brieger 
have found that it is constantly present in normal human faeces. It 
is probable, as asserted by Salkowski, that the acid is formed in the 
organism as a late product of the pancreatic digestion. Its elimination 


600 


GENERAL REMEDIES. 


by the urine is enormously increased in ileus (one-hundredfold, Sal- 
kowski), and diminished in anaemia, phthisis, scorbutus, scrofula, and 
cancer (Brieger, Med. Centralbl ., 1878, p. 545). Hoppe-Seyler’s theory 
that the acid does not pre-exist in the urine, but is formed out of in¬ 
dican during the processes employed for procuring it, is not tenable. 
It appears to be formed from the albuminous substances, tyrosin being 
an intermediate product, since Brieger has found that the taking of 
large doses of tyrosin is followed not by elimination of tyrosin, but by 
a great increase of the urinary phenol. It is quite possible that the 
phenol is formed in the intestine by fermentative changes, as Baumann 
has noticed the closely-allied substance indol produced by the putre¬ 
factive changes in a mixture of albuminous substance with a small 
quantity of pancreas and a little carbonate of ammonium. (See Pfluger's 
Archiv, xii. 862.) In this connection it is interesting to note that 
Christiani has not been able to find phenol in the urine of chickens fed 
upon vegetable diet, although a notable amount is present when a flesh 
diet is allowed ( Zeitschr. f. Physiol. Chem., ii.). In a series of experi¬ 
ments Dr. I. Munk obtained three grammes as the average excretion 
of twenty-four hours from a horse {Arch. f. Thierheilkunde, viii. 104). 

Local Action. —The local action of carbolic acid is very decided. 
Applied to the skin, it produces at once a burning pain, and in a few 
minutes a peculiar white spot. If the acid be removed, the pain con¬ 
tinues for some minutes, and the white color changes to a dark or red 
stain, which gradually fades away as the skin desquamates. On a pro¬ 
longed application, carbolic acid does not blister, but causes the forma¬ 
tion of an eschar. A curious local action of carbolic acid, to which 
attention was drawn almost simultaneously by Dr. Erasmus Wilson 
(Journal of Cutaneous Medicine, June, 1870) and by Dr. J. II. Bill, U.S.A. 
{American Journal of the Medical Sciences , Oct. 1870), is due to the 
property which it has when applied in concentrated form of causing 
very great local anaesthesia. The complete loss of feeling is not con¬ 
fined to the tissue killed by the drug, but extends some little distance 
inwards. 

Therapeutics.— In the doses in which it is usually given, carbolic 
acid exerts no perceptible effect upon the system. It has been used to 
a considerable extent in zymotic diseases for the purpose of destroying 
the poison in the blood. Even, however, if such poison be micrococci 
or bacteria there is no reason for believing that these are more sensitive 
to the action of the drug than is the human organism; and clinical ex¬ 
perience with the acid in these diseases has certainly demonstrated its 
uselessness. The study of its physiological action has failed to show 
the possession of any property which should render the medicine valu¬ 
able in constitutional diseases. Our physiological knowledge conforms 
with clinical experience in showing that carbolic acid is of no value in 
constitutional diseases, and it is employed directly in medicine only for 
its local effects. 


ANTIPYRETICS. 


601 


Internally it is of value in nervous vomiting , especially when there is 
an irritability of the gastric nerves. One or two drops of it, or of 
creasote, maj^ be given in emulsion every three or four hours in such 
cases. The good which it achieves is probably dependent upon its local 
anaesthetic properties. In gangrene of the lu?ig, the internal administra¬ 
tion of carbolic acid, combined with the use of a weak solution (ten 
drops to the ounce) by atomization, is sometimes of service. 

Professor M. H. Desplats has used carbolic acid as an antipyretic 
with asserted good results, but the practice has not been followed. He 
gives from fifteen to thirty grains of the acid by the rectum, and states 
that he has administered as much as three drachms a day without 
injury ( Gaz. Hebd., 1880, xvii. 628). 

Its external use is much more important than its internal employ¬ 
ment, but belongs to the domain of the surgeon rather than of the 
physician, and I shall only discuss it briefly.* As a caustic , carbolic 
acid is not available when large masses of tissue are to be destroyed, 
but it may often be employed with advantage against condylomata and 
similar growths. Even in such cases, to be efficient, it must be in the 
most concentrated form. In diphtheria , idcerated sore throat , and aph¬ 
thous stomatitis , its concentrated solution in glycerin may be carefully 
applied, by means of a camel’s-hair brush or a mop, as a mild caustic 
scarcely capable of destroying sound tissue. In various forms of in¬ 
dolent ulcer , in ill-conditioned wounds , carbolic acid affords a very useful 
stimulant application; in “ burns," properly diluted with oil (gtt. x to 
f3i), it is one of the very best remedies that can be used, relieving pain 
by its anaesthetic properties and at the same time lessening suppuration 
and facilitating cicatrization. 

Dr. Bill (loc. cit .) has employed carbolic acid as a local anaesthetic, in 
a number of cases of minor operations, always with the result of pre¬ 
venting or greatly mitigating pain. His plan in opening a felon is to 
soak the fingers for fifteen minutes in warm water containing three per 
cent, of the acid, and then to draw a brush dipped in the concentrated 
acid along the line of the incision. Sometimes, when a deep incision 
is necessary, a sensitive part is reached. Under these circumstances he 
is accustomed to brush out the wound anew with the anesthetic. 

So far as I know, the first to suggest and employ deep injections of 
carbolic acid as a means of combating deep-seated inflammations was Dr. 
J. A. Eames (Brit. Med. Journ., May, 1873); but the method has been 
especially studied by Professor C. Ilueter ( Deutsch. Zeitschr. f. Chir., iv. 
1874; Schmidt's Jahrbucher , Bd. clxiv. p. 144). He employs a two-per¬ 
cent. solution, a weaker one not being efficient, and a stronger one en¬ 
dangering the coagulation of the blood and of the exudation in the 


# Perhaps it is proper here to call attention to the experiments of Dr. L. A. Stimson 
(Amer. Journ. Med. Sci., Ixxix. 83), which seem to show that the carbolic acid spray, as used 
by Lister, has no effect upon floating germs. 



602 


GENERAL REMEDIES. 


inflamed tissue. Of this solution he uses at one time never more than 
half a drachm, and generally less than this. After anaesthetizing the 
skin by the local application of carbolic acid, he introduces the hollow 
needle into the centre of the inflammation obliquely, so as to diminish 
as far as possible the chances of the introduction of air. To avoid the 
danger of throwing the acid directly into the circulation, the needle is 
not connected with the syringe until it is seen that no blood comes out 
through it. If the extent of inflamed tissue be large, several injections 
are practised at one time: in acute cases they are usually repeated 
twice a day, in chronic cases every day, or every other day. Dr. Hueter 
has made about a thousand of these “parenchymatous injections,” and 
only ten times has any inflammation been excited by them. The pain 
is usually very slight, and the relief apparent in one or two days at 
most. In chronic synovitis , the drug is thrown into the joint once in 
two or three days, and the method has been practised by Dr. Hueter 
with asserted extraordinary success in glandular swellings and inflam¬ 
mations , phlegmons of all grades and characters, erysipelas , poisoned 
wounds , inflamed bursce, hydrocele , and even in hone-disease. 

The practice has been followed with satisfaction by Dr. Aufrecht in 
erysipelas (Centralbl. f. Med. Wissen ., 1874, p. 129), by Senator ( Berlin. 
Klin. Wochenschr ., 1876, p. 69), Mader (Centralbl. f. Chir ., 1877, p. 376), 
and Kunze in acute and subacute rheumatism (Centralbl. f. Med. Wissen ., 
1874, p. 479), by Hagen in several diverse inflammations (Schmidt's 
Jahrb., Bd. clxiv. p. 146), and by I. Schmidt in chronic synovitis (Cen¬ 
tralbl. f. Chir., 1876, p. 552). Dr. Hagen has even used these injections 
with very excellent results in three cases of severe angina which he 
believed threatened diphtheria, throwing the remedy into the neighbor¬ 
hood of the second tracheal cartilage. Dr. Moses K. Taylor (Amer. 
Journ. Med. Sci., April, 1882) has used injections in one hundred and 
fifty cases of buboes and otherwise enlarged glands, with uniform suc¬ 
cess. He throws into the inflamed part about twenty minims of an 
eight-grain solution of the acid, previously chilling the surface with 
an ether spray. The total evidence seems to show that this method 
of treatment is both safe and effective. 

Toxicology.— The number of fatal cases of carbolic acid poisoning 
now on record is quite large, and the list is constantly growing.* The 
symptoms, although varying within certain limits, are, on the whole, 
quite uniform. They almost always appear in a very short time after 
the ingestion of the poison. Sometimes the rapidity of the fatal result 
almost equals that of prussic acid poisoning. Thus, Dr. Taylor, U.S.N. 
(Phila. Med. Times , vol. ii. p. 284) records a case in which about an 
ounce is supposed to have been ingested, and in which the man fell 
unconscious within ten seconds after taking the fatal draught, two 


* References to one hundred and sixty-nine cases of carbolic acid poisoning have been 
collected by H. Robert ( Schmidt's Jahrb., cxciv. 229). 



ANTIPYRETICS. 


603 


minutes afterwards was totally unconscious, pulseless, with irregular 
distant gasping respirations, and in less than a minute later was dead, 
apparently from cardiac paralysis, since the impulse of the heart was 
entirely lost before the cessation of respiration. Generally some min¬ 
utes elapse before the symptoms develop themselves: nausea, cold 
sweats,* and stupor deepening rapidly into insensibility and collapse, 
are the most frequent phenomena. During the period of insensibility, 
complete abolition of reflex movements and anaesthesia of the mucous 
membranes have sometimes been noted (case, Journ. de Pharm. et de 
Chim., Dec. 1871): indeed, it is scarcely doubtful that in all cases both 
sensibility and reflex movements are profoundly affected. Convulsions 
are only exceptionally present. The symptoms of collapse are usually 
well developed, and the pulse is generally feeble and very frequent, but 
has been recorded as being reduced to from forty to fifty per minute 
(case, Med. Times and Gaz ., April, 1871). Haemoglobinuria has been 
noted. Dyspnoea is often extreme ; the respirations may be stertorous, 
are usually very rapid, and, in the advanced stages, shallow. In very 
rapid cases they are irregular and suspended at intervals. Total tem¬ 
porary amaurosis, with contraction of the pupil, has been noted (case, 
Berlin. Klin. Wochensehr., xix. 748). Death may occur in a very few 
minutes ; but usually the patient lives from one to ten hours, and life has 
been protracted for sixty hours (case, Sydenham Soc. Year-Book , p. 446 ? 
1871-72; amount taken, one and a half ounces of the commercial acid). 
In some cases a great amendment has occurred and consciousness been 
restored, but after some hours rather sudden fatal collapse has come on 
(case, Brit. Med. Journ., Feb. 1861). The minimum fatal dose of car- 
bolic acid is not known; but half an ounce has several times caused 
death {Med. Times and Gazette, 1870, ii. 474; Phila. Med. and Surg. 
Rep., Jan. 1870; Lancet , 1878, ii. 510), and a little over a drachm is 
reported to have killed a man sixty-four years old ( London Lancet, 
1869, i.); in a case of puerperal metro-peritonitis fifty drops contrib¬ 
uted towards the fatal result (Dr. A. D. L. Napier, Trans. Med.-Chir. 
Soc. Edinb., ii. 75). 

The free external use of carbolic acid is by no means devoid of 
danger : Dr. Falckson, after two hours’ exposure to carbolic acid spray, 
recovered from his urine thirty grains of carbolic acid {Arch. f. Klin. 
Chirurg., xxvi. 204), and he describes a marasmus or chronic poisoning 
resulting from the surgical use of the remedy. The symptoms are 
said to be headache, loss of appetite, bronchial irritation, which finally 
may become very severe, severe pains in the region of the kidney, re¬ 
curring vomiting, pruritus, or various parresthesise, and loss of power in 
the legs. (See also paper by Dr. Wallace, Brit. Med. Journ., April. 1870.) 

There have been numerous cases of acute poisoning from the ex- 

* The excessive sweating sometimes seen in carbolic acid poisoning Th. Gies believes to 
be of central origin, since in a poisoned cat with one sciatic nerve cut, no sweat came from 
the injured part. 



604 


GENERAL REMEDIES. 


ternal use of carbolic acid. A single vaginal injection has produced 
very severe constitutional results ( Schmidt's Jahrb., Bd. cci. p. 129). 
Professor R. Kohler reports ( Ibid., Bd. civ. p. 276) the cases of two 
journeymen joiners, suffering from scabies, who applied externally 
each about a half-ounce of carbolic acid, in watery solution. One of 
them was found dead. His fellow, who suffered from unconsciousness 
and drunken delirium ending in unquiet sleep, after his recovery stated 
that directly after rubbing himself with the solution he had giddiness, 
that seven or eight minutes later his companion complained of burning, 
but that of what took place after this he knew nothing.* It is scarcely 
necessary to refer in detail to cases in which serious results have fol¬ 
lowed the surgical use of carbolic aeid.f In the London Medical Rec¬ 
ord , Oct. 15, 1887, is recorded a very severe case of poisoning in an 
infant produced by the use of carbolized cotton wool. In vol. ii., 1870, 
of the Medical Times and Gazette is narrated a curious case of fatal 
poisoning from inflammation of the external parts and of the rectum, 
produced in a child by its sitting upon a block on wKich some of the 
acid had been thrown. A serious result which has been known to 
follow the application of phenol to a slight wound of the finger is 
gangrene of the whole member (LAbeille Med., Dec. 11, 1871). It is 
affirmed, with somewhat doubtful truth, that the absorption in these 
cases is through the surrounding skin, rather than from the wound, 
and that if contact of the carbolic acid dressing with the skin be pre¬ 
vented by a coating of gutta-percha upon the latter, all danger of 
poisoning is averted {Med. Times and Gaz., 1878, ii. 461). 

The diagnosis of carbolic acid poisoning during life ought in most 
cases to be practicable ; for, although the symptoms simulate some forms 
of apoplexy too closely for the diagnosis to be made from them, very 
generally the odor of the drug can be perceived about the person of 
the victim, and close examination of the mouth will nearly always re¬ 
veal traces of the local action of the acid, in the form of white, hard¬ 
ened, or corrugated patches of mucous membrane. Either these, or a 
blackish urine in conjunction with the symptoms, are diagnostic. After 
death a strong odor of carbolic acid can almost always be perceived 
when the body is opened, and the mucous membrane of the stomach 
affords very reliable evidence as to the cause of death. According to 
Dr. A. Hiller, the urine of carbolic acid poisoning as first passed varies 
from a clear yellow to a golden yellow, and upon standing in the air 
becomes dark olive and finally often blackish green. Sometimes it is 
grass-green, but it may appear to be normal (case, Schmidt's Jahrb., Bd. 
ccii., p. 238). This carbolic acid urine, if treated with nitric acid and 


* For other fatal cases, consult Bull. Thirap., t. Ixxv. p. 285. 

•(• Consult British Medical Journal, March 1, 1873,—death from absorption by a wound 
four inches long; Neio York Medical Gazette, April, 1871; British Medical Journal, 1868, p. 
220,—two fatal cases; Med. Times and Gaz., 1878, ii. 461; Wiener Med. Woclienschrift, 
1879, xxix. 1233. 



ANTIPYRETICS. 


605 


afterwards with potassa, becomes, after a certain degree of concentra¬ 
tion, blood-red or brown-red, changing through pea-green to violet. 
Carbolic acid mixed with urine does not answer this test ( Schmidt's 
Jahrbucher , Bd. clxiv. p. 144).* The absence of carbolic acid urine 
proves that the case is not one of poisoning. Baumann and Hueter 
declare that the earliest sjnnptom of the poisoning is disappearance of 
the sulphates from the urine ( Zeitschr. f. Physiol. Cliem ., i.).f 

In a case of carbolic acid poisouing emetics are generally useless, 
owing to the paralysis of the stomach which exists, and the stomach- 
pump must be employed to empty the viscus. Alkalies in excess are 
of some value, according to Iiusemann, who employs a saccharate of 
lime ,l and the free ingestion of oils was formerly recommended; but to 
Baumann and Hueter (Med. Times and Gaz., ii., 1878) belongs the credit 
of discovering the proper antidote to carbolic acid. They found that 
during carbolic acid poisoning the sulphates disappear from the urine, 
and that if a soluble sulphate be given freely to an animal poisoned 
with carbolic acid, the latter will be converted into a harmless sulpho- 
carbolic acid.§ Sonnenburg discovered that in patients presenting the 
dark-colored urine and other symptoms of poisoning resulting from the 
too free external use of the acid all trouble disappears upon the adminis¬ 
tration of the sulphate of sodium; and Dr. D. Cerna (Phila. Med. Times , 
ix. 593) has, in an elaborate series of experiments upon animals, em¬ 
ployed the sulphate of magnesium with entire success: so that it may 
be considered established that a soluble sulphate is the proper antidote 
to carbolic acid, and that it should be employed very freely and in 
all stages of the toxtemia, as being capable of neutralizing the poison 
in the blood. The chemical history of phenol inside of the body 
explains why the sulphates are so efficient. Dr. De la Bate (Bull. 
Gen. de Therap ., cv. 418) affirms that he obtained very happy results in 
one case of carbolic acid poisoning from inhalations of oxygen. Dr. 
Jos. Szydlowsky saved a pulseless and apparently dying child ten hours 
after the ingestion of the carbolic acid, by hypodermic injections of 
ether and the administration of dilute sulphuric acid and sulphate of 
sodium (St. Petersb. Med. Wochenschr., 1883, x. 87). So long, therefore, 
as a patient can swallow, the antidote of carbolic acid should be given. 


* For method of detecting carbolic acid in urine, see Lond. Med. Rec., 1877, p. 455. 
f To detect the diminution of sulphates in the urine, remove any albumen present by 
boiling, acidify with acetic acid, and add chloride of barium in excess. This reagent gives a 
milky cloud of sulphate of barium in the presence of sulphates, but a mere haze or no alter¬ 
ation in carbolic acid poisoning. 

J Dissolve sixteen parts of sugar in forty parts of distilled water, and add five parts of 
caustic lime; digest for three days, stirring from time to time, filter, and evaporate to dryness. 
The product thus obtained dissolves easily in water. 

$ For a study of sulpho-carbolic acid, see La Tribune Med., July, 1884, 328. M. F. 
Vigier affirms that, while not poisonous to the higher animals, it is an active antiferment. M. 
Rabuteau ( Compt.-Rend . Soc. Biol., 1882, iii. 42) finds that the acid is simply a feeble pur¬ 
gative. 



606 


GENERAL REMEDIES. 


Carbolic Acid as an Antiseptic and Germicide .—In 1870, Grace Calvert 
proved that albumen was preserved for eleven days when mixed with 
carbolic acid, and Dr. John Dougall that one twenty-five-hundredth 
part would destroy spermatozoa and the higher infusoria. Schroeter, 
in 1878, found that 0.0501 per cent, (one in two thousand) would keep 
flesh for four weeks, and 0.2 per cent, permanently. It was soon found 
that the acid acted even more powerfully upon moulds than upon putre¬ 
factive organisms. 

The first to study the action of carbolic acid upon vaccine lymph 
were Braid wood and Vacher, and their experiments have been repeated 
and extended by Dougall, by J. W. Miller, by Hoppe-Seyler, and by 
Baxter. Each of the last two observers found that two per cent, of 
the carbolic acid destroyed with certainty the infective power of vac¬ 
cine, a conclusion, on the whole, not discordant with that of the other 
observers. 

The germicidal power of the drug has also been studied by Hugge, 
Rosenbach, Baxter, Sternberg, Davaine, Koch and Blyth, Arloing, Corne- 
vin, Thomas, and various other observers, upon almost all the known 
forms of infective organisms. 

Their concordant testimony shows that one per cent, in an aqueous 
solution will destroy with certainty the virulence of ordinary septic 
and purulent matters, of the tubercle-bacillus, and of the micrococci of 
fowl-cholera; some of the organisms related to putrefaction have also 
been destroyed by solutions of this strength : but to produce these re¬ 
sults with certainty the contact with the disinfectant had to be con¬ 
tinued for many hours. Two per cent, of the acid in an aqueous solu¬ 
tion was required to destroy the infection of vaccine or of glanders. 

There are, it is true, some experiments which seem to be discordant 
with these results, especially those of Kotter and of Jalan de la Croix, 
who found that as much as ten to thirty per cent, of the acid was 
necessary to prevent the movements of bacteria in putrid infusions of 
beef; but there was probably some error in their experimental methods. 

As a vapor, carbolic acid seems to act very feebly as a disinfectant 
or germicide, and it is very evident that the popular estimate of the 
value of carbolic acid is too high. 

Creasotum, U.S.— Creasote, a substance closely allied to carbolic 
acid, is prepared from wood-tar, by a process similar to that by 
which the latter is obtained from coal-tar. It closely resembles car¬ 
bolic acid solutions, but may at once be distinguished by its odor, which 
is much more smoky. Moreover, if a splinter of pine be dipped into 
carbolic acid, and then into muriatic acid, the wood, after the lapse of 
half an hour, assumes a distinct blue color. This does not occur with 
creasote. Again, carbolic acid does, and creasote does not, coagulate 
collodion; and by the action of nitric acid creasote is converted into 
oxalic acid, resinous matter, and but a small proportion of picric acid. 


ANTIPYRETICS. 


607 


Creasote is at present a rare drug, the material usually sold under its 
name in the drug-stores being really a solution of carbolic acid. In 
their therapeutic value the two substances are probably about equal.* 
Five cases of ereasote-poisoning are on record: Muller ( Wurtemb. Cor- 
respondenz-Blatt , 1869), T. Stevenson {Guy's Hosp. Rep., 1875, xx. 144), 
Piirckhauer ( Friedreich's Blatter f. Gericht. Med., 1883, 430), F. Grinell 
{Med. News, xl. 345), Manouvriez ( Soc. Med. Legale de France, vii. 108). 
The symptoms are like those of carbolic acid poisoning,— i.e., uncon¬ 
sciousness, collapse, stertorous breathing, and great cardiac depression. 

Menthol, f or Oil of Peppermint Camphor, has lately obtained great 
notoriety as a local anaesthetic, and, if freely rubbed upon a part, it 
undoubtedly will often relieve neuralgic pains when they are super¬ 
ficial and peripheral in their origin : its solution (2 to 10 grs.—fgi 
water) is said also to be very effective in pruritus ani, chronic painful 
eczemas, urticaria, etc. Its physiological action has been studied by 
Paolo Pellacani {Arch. f. Exper. Path. u. Pliarm., xvii. 376). In the 
frog it causes paralysis, first of the spinal centres and finally of the 
nerve-trunks. In the mammals both mobility and sensibility are de¬ 
pressed, the animal grows cold, the respiration becomes slow and shal¬ 
low. Small doses excite, larger paralyze the frog’s heart. In the poi¬ 
soned mammal there were very curious, unexplained rhythms of rise 
and fall of the blood-pressure. Dr. Goldscheider {Archiv f. Physiol., 
1886) has been led to the conclusion that the sensation of cold pro¬ 
duced by the local application of menthol is due to a special influence 
exerted upon the special nerves of temperature by finding—first, that 
after the application of a solution of menthol in lanolin the local tem¬ 
perature is increased 2° C., although a marked sensation of cold has been 
produced, and, secondly, that the cold is not due to evaporation, because 
covering the part to which the menthol is applied with a watch-glass 
does not affect the sensation. The doctor also found that if the menthol 
ointment were applied to one side of the forehead, bodies which previ¬ 
ously had caused the sensation of cold no longer did so, and that appli¬ 
cations of menthol caused the sensation of warmth upon the elbow and 
the volar side of the wrist, positions at which, according to Professor 
Herzen, similar warm sensations are caused by pressure upon the nerve- 
trunks. Dr. S. A. Eussell {Med. Rec., Nov. 1885) affirms that menthol 
has a remarkable power of controlling superficial inflammations. He 
applies an ethereal solution, of the strength of from 10 to 50 per cent., 
two or three times a day by means of a camel’s-hair pencil, and claims 
to control thereby boils, carbuncles, superficial abscesses, etc. 


* Creosol appears to be the basis of pure creasote; from it is easily prepared creosotinic 
acid. This substance has been found by E. Buss ( Berlin. Klin. Wochenschr., 1876, p. 445) to 
have active antipyretic and other therapeutic properties. 

f Thymol and menthol are not known to bo antipyretics, but are here considered because 
they probably are physiologically allied to carbolic acid. 



608 


GENERAL REMEDIES. 


THYMOL. U.S. 

Thymol is found in the oil of thyme and of some other plants. It 
occurs either as an uncrystallizable liquid or in white rhombic or acicu- 
lar crystals. It has been used with satisfaction as a substitute for car¬ 
bolic acid by Volkmann and Ranke, of Halle, and other practitioners, 
but, although it is undoubtedly powerfully antiseptic, does not seem to 
have rapidly gained favor. Its fragrant odor has proved a decided 
disadvantage, in summer at least, by attracting swarms of flies. It is 
not free from poisonous properties. On the other hand, it is claimed 
that it does not irritate the skin, and has a decided influence in pre¬ 
venting discharges. Spencer Wells employs its watery solution (1 to 
1000 of warm water); Yolkmann, thymol 1 part, glycerin 20 parts, 
alcohol 10 parts, water 1000 parts. It has been used internally by 
Biilz (London Med. Record , 1878) in doses of thirty grains a day, or 
less. In a few instances nausea and vomiting were caused. There was 
abundant sweating, singing in the ears, deafness, constriction in the 
forehead, reduction of temperature, and frequently diarrhoea. The 
urine was dark greenish, yellowish brown by transmitted light, free 
from albumen, becoming cloudy and grayish white on the addition of 
the tincture of the chloride of iron. Violent delirium occurred several 
times, also marked collapse, and, in one case of typhoid fever, uncon¬ 
sciousness, with most alarming collapse. Dr. Biilz concludes that the 
remedy is much less certain and more dangerous as an antipyretic than 
is salicylic acid. The possession of poisonous properties by thymol has 
been confirmed by the recent experiments of Dr. B. Kiissner {Med. 
Times and Gaz., Dec. 1878, p. 716). This observer found that when 
given to dogs and rabbits by the stomach the poison acts very slowly 
and feebly, on account of its slow absorption, but that when injected 
into the circulation it produces death by failure of respiration. Coma is 
developed some time before death, and the blood-pressure, which at first 
maintains itself, now falls steadily. Post-mortem examination failed to 
detect fatty degeneration or other lesion in either the solid tissues or 
the blood. The continuous repeated exhibition of small doses of thymol 
had no perceptible effect, except to interfere in some way with nutri¬ 
tion, so that the animals lost flesh. According to a statement in Hoff¬ 
mann und Schwalbe's Jahresb., 1879, 208, Kiissner has found that thymol 
has the power of dissolving the red blood-corpuscles. 

The evidence already forthcoming indicates that the therapeutic use 
of thymol will be very limited. Its costliness and the absence of marked 
advantages in its favor militate against its being largely used externally. 
There is, however, one local employment of it which is important,— 
namely, as a detergent antiseptic in various ulcerated and diseased 
conditions of the mouth. For such use its agreeable taste and odor 
preeminently fit it. That anything is to be gained by its internal ad¬ 
ministration is not at all certain. Enough has been said to condemn it 


ANTIPYRETICS. 


609 


as an antipyretic. Kiissner found the sugar in the urine of a patient 
with diabetes reduced by from one to two grammes of thymol per diem; 
but Fiirbringer ( Deutsches Archiv f. Klin. Med ., xxi.) reports a case in 
which one gramme daily increased the sugar. Kiissner thinks thymol 
(three to five minims of a one-per-cent, solution three times a day) of 
value in vesical catarrh and in infantile diarrhoea , and found that inhala¬ 
tions (1 part to 1000) diminish the fever and expectoration of phthisical 
patients. 

Thymol was recommended by Dr. Martime as an antiseptic sedative 
for the relief of the diarrhoeas of typhoid fever, intestinal catarrh, etc. 
Dr. F. P. Henry, following this practice, believes that he has obtained 
very good results in doses of thirty grains in the twenty-four hours. 
{Med. JYews, Sept. 18, 1887.) 


RESORCIN. 

In 1864 Hlasiwetz and Barth produced from galbanum a substance 
to which the name of resorcin was given, and which is now obtained 
as a derivative of phenol. It occurs in colorless, short, aromatic prisms 
or plates of an unpleasantly sweet, somewhat acrid taste, which on ex¬ 
posure to the air become reddish. It is freely soluble in one and one- 
quarter parts of water, in alcohol, in ether, and in about twenty parts 
of fixed oil. 

Physiological Action.— Resorcin appears in its physiological prop¬ 
erties to be allied to carbolic acid. It is distinctly poisonous to the 
lower organisms, and, according to Martin Cohn {Inaug. Biss., Berlin, 
1882) and Dr. Andeer {Ueber das Resorcin , Wurzburg, 1880; also 
Centralbl. f. Med. Wissens., 1881), a one-per-cent, solution of it is suffi¬ 
cient to arrest for a long time putrefactive changes in the urine, or¬ 
ganic infusions, and even animal tissues. Platt states (Amer. Journ. 
Med. Sci., vol. i., 1883), however, that it is distinctly inferior to carbolic 
acid as an antiseptic. When given to the lower animals (Dujardin- 
Beaumetz, Bull. Therap., ci. 113) it causes tremors, loss of conscious¬ 
ness, and epileptiform convulsions, which, when the dose has been 
sufficiently large, become more and more violent, until the increasing 
disturbance of breathing ends in respiratory arrest. During the 
spasms the temperature of the animal is distinctly elevated, but when 
there is quiet narcosis it may fall below normal. The urine becomes 
olive-green, deepening into blackish. 

No case of fatal poisoning in man has been recorded. The largest 
therapeutic doses produce flushing of the face, with giddiness, buzzing 
in the ears, and some quickening of the breathing and pulse, followed 
after a time by violent perspiration. Sixty grains caused in man giddi¬ 
ness and violent perspiration, with marked anxiety, ending in collapse 
and unconsciousness. Andeer took about one hundred and fifty grains 
of resorcin, dissolved in a pint of water, during fifteen minutes. After 
disturbance of the cerebration and of the special senses, he fell into a 

39 


610 


GENERAL REMEDIES. 


condition of collapse, with cold extremities, epileptiform convulsions 
with loss of consciousness, opisthotonos, and marked disturbance of 
the respiration. Consciousness did not return for five hours. Dr. 
Murrell records (Med. Times and Gaz ., vol. ii., 1881) a case in which a 
woman took one hundred and twenty grains of resorcin, and imme¬ 
diately felt giddy, had sensation of pins and needles all over her, and a 
few minutes later was insensible, with closed eyes, clinched hands, 
pallid, blanched lips, dry tongue, normal pupils, and insensible conjunc¬ 
tiva ; the temperature was 94°; the reflexes were entirely gone; the 
pulse was weak and thready. The chief action of resorcin is upon the 
nerve-centres, although, like carbolic acid, it probably affects all highly- 
organized tissues. The experiments of Dr. Beyer ( Amer. Journ. Med. 
Sci., April, 1886) show that it has a direct action upon the heart,—mod¬ 
erate doses paralyzing the sinus and auricles, and very large doses 
causing immediate diastolic arrest of the whole heart. 

Therapeutics. —As an antipyretic resorcin has been used by Licht- 
heim ( Corresp.-Blatt f. Schweizer Aerzte , July, 1880), Murrell, and other 
clinicians. It is probably capable of acting effectively, but it appears 
to be distinctly inferior to and more dangerous than other antipy¬ 
retics, and of late years has been employed by the profession solely 
as a topical remedy in diseases of the skin and of the mucous mem¬ 
brane. Dr. Andeer originally recommended it as an antiseptic stim 
ulant application in uterine and vaginal disease, stating that it must be 
employed in the form of an ointment spread upon tampons, as the 
injection of a two-per-cent, solution is apt to produce severe uterine 
contractions. It has been strongly recommended by Hoefer, Lichtheim, 
Janicke, and Fliesburg (see Therap. Gaz., vols. ii. and iii.), and other 
physicians, in the treatment of various irritations of the gastrointes¬ 
tinal mucous membrane, in which it is believed to do good partly by 
checking fermentative changes in the contents of the alimentary canal 
and partly by a specific action upon the mucous membrane: in this man¬ 
ner it has been employed in gastric ulcer, vomiting, and cholera infantum 
and other diarrhoeas. It has been used also to some extent with alleged 
good result in inflammations of the upper respiratory passages. Thus, 
Fliesburg states that in hay fever a spray of thirty to fifty per cent, 
of resorcin, given two or three times a day, is of the greatest service, 
and that it is possible to arrest whooping-cough by the frequent employ¬ 
ment of a spray from a five- to twenty-per-cent, solution. Arntzenius 
also commends the remedy highly in the same disease. The solution 
of from one to five per cent, has been employed with alleged excel¬ 
lent results as a local application in chronic otitis, gonorrhoea, leucor- 
rhcea, etc. In cystitis resorcin may be administered by the mouth, 
or applied in weak solution by injection. It is said to be an active 
parasiticide, and to be valuable in the treatment of the various skin- 
diseases dependent upon the presence of an animalcule or of a fun¬ 
gous growth. Too irritating for acute inflammations of the skin, it is 


ANTIPYRETICS. 


611 


alleged to exert a powerful effect on recent cell-infiltrations, and to be 
extraordinarily successful in chronic eczema , where there is much thick¬ 
ening from exudation, and even in psoriasis. According to Andeer, re¬ 
sorcin, in powder or in saturated ethereal solution, is a feeble caustic, 
useful in the treatment of chancres , of papilloma , and even of epithelioma 
and diphtheria. 

Murrell affirms that he has often given forty grains of resorcin at a 
dose every four hours without the production of any unpleasant symp¬ 
toms ; but this is probably because he had an impure article. Of pure 
resorcin the dose may be set down as from two to five grains. For use 
upon the mucous membrane the strength of the solution may vary 
from one to twenty per cent. Upon the skin the solution or ointment 
may vary from five to thirty per cent. 

ACIDUM SALICYLICUM—SALICYLIC ACID. U.S. 

Salicylic acid has long been known to chemistry, but has only re¬ 
cently been rendered available by Professor II. Kolbe, who discovered 
that it could be prepared by treating a solution of carbolic acid in 
caustic soda with carbonic acid at a moderate heat. It occurs in long 
acicular crystals or in the form of a white, dull powder, of a peculiar 
pungent odor, and a mild, peculiar taste, accompanied by a transient 
sense of numbness. 

It is soluble in three hundred parts of water, and in four parts of 
alcohol. By warming, glycerin can readily be made to dissolve four 
grains to the drachm; no precipitation occurs on cooling. 

Physiological Action. —When salicylic acid is given to man in 
doses just sufficient to manifest its presence, symptoms closely resem¬ 
bling cinchonism result. These are fulness of the head, with roaring 
and buzzing in the ears. After larger doses, to these symptoms are 
added distress in the head, or positive headache, disturbances of hear¬ 
ing and vision (deafness, amblyopia, partial blindness), and excessive 
sweating. According to Beiss ( Berliner Klin. Wochenschrift , 1875, p. 
674), decided fall of temperature without alteration of the pulse also 
occurs; but this is denied by other observers. The action upon the 
system of the acid and of its sodium salts (also ammonium salt, Mar- 
tenson, Petersh. Med. Zeitschrift, 1875, p. 343) appears to be identical, 
and, as several cases of poisoning with one or other of these agents have 
occurred, we are able to trace the toxic manifestations. Along with 
an intensification of the symptoms already mentioned, there are ptosis, 
deafness, strabismus, mydriasis, disturbance of respiration, excessive 
restlessness passing into delirium, slow laboring pulse, olive-green urine, 
and involuntary evacuations. In some eases the temperature has re¬ 
mained about normal, but in others has approached that of collapse. 
The respiration appears to be almost characteristic: it is both quick¬ 
ened and deepened. In some cases the dyspnoea has been extreme, and 
given rise to the most violent respiratory efforts. The suggestion of 


612 


GENERAL REMEDIES. 


Dr. Hastreiter (. Med.-Chir. Corresp.-Blatt, Buffalo, May, 1884) that this 
dyspnoea is due to pulmonary congestion produced by cardiac weakness 
is plausible. Sweating usually is very free, and the urine early be¬ 
comes albuminous. Yarious local evidences of vaso-motor weakness 
may supervene, such as rapidly appearing bed-sores at points subjected 
to pressure, and transitory dark-colored maculse on various parts of 
the body.* In several cases death was probably produced by the acid. 
The most conclusive case is that of H. Quincke ( Berlin. Klin. Wochen- 
schrift , xix. 710). The chief post-mortem change was a breaking down 
of the blood, congestion of most of the viscera, and ecchymoses on the 
serous membranes.f 

In rare instances even the therapeutic use of salicylic acid has pro¬ 
duced severe skin-eruptions. The form has been sometimes like that 
of urticaria, in other cases it has been exanthematous or even bulla- 
tous. (For references to cases, see Dr. S. Rosenberg, Deutsch. Med. 
Wochenschr., 1886, 569.) 

In some cases of salicylic acid poisoning the mental disturbance has 
been prolonged for a week or more. It is stated that upon drunk¬ 
ards the acid acts very unfavorably, violent delirium being a common 
and early symptom of its influence. There are also some persons whose 
idiosyncrasies are such that mental disturbance is produced even by 
moderate doses of the acid. In some cases the delirium is cheerful, in 
others it is melancholic in type. In the mildest form it is manifested 
only by a tendency to dream actively and to talk during sleep. In 
other cases the roaring in the ears soon becomes associated with dis¬ 
turbances of vision, which grow more marked until the patient not 
only sees objects in false appearances and colors but has absolute illu¬ 
sions. The hallucinations are apt to take the shapes of animals such as 
are seen in delirium tremens, but there is usually little or no terror, and 
the troops of images may march to beautiful music. In other cases 
the delirium amounts to acute mania, with restlessness, violent outcries, 
and even a fury of fighting.£ 

When given to dogs by the mouth in large doses, salicylic acid is 
said to be usually vomited. According to Laborde [Bull, de Therap ., 


® For cases, consult Deutsches Archiv f. Klin. Med., xix. 319; Centralbl. f. Chirurgie, 
1877, p. 278,—401 grains of salicylate of sodium taken in twelve hours; London Lancet, 1876, 
2, 681; Berlin. Klin. Wochenschrift, No. 4, 8, 1876; and Bull. Tlierap., 1877, xciii. 25. 

t In the case recorded in the Virginia Med. Monthly, June, 1877, forty-eight grains of 
the acid were taken in four hours. The symptoms were violent vomiting, headache, total un¬ 
consciousness, and stertorous breathing. Death occurred forty hours after the first dose. My 
belief is that either much more of the acid than forty-eight grains was taken, or, what is 
more probable, death was from some other cause. See also Med. and Surg. Reporter, 1878. 
There is no probability that in the alleged case of poisoning reported by Dr. Frank Ogston 
{Brit. Med. Journ., 1883, i. 869) the salicylate had anything to do with the untoward symp¬ 
toms or result. The case reported by Dixneuf {Thlse, Paris, 1S78), also that of Empis and 
Gubler {Bull, de l’Acad. MSd., 1877), I have not had opportunity to examine. 

J For collection of references of cases, see paper by J. Krueg ( Wien. Med. Presse, 1886, 
xxvii. 405). 



ANTIPYRETICS. 


G13 


xciii. 276), when from four to five grammes of salicylate of sodium 
are injected into the veins of the dog the first result is a slight accel¬ 
eration of the heart’s action and of breathing; this is followed by 
efforts at vomiting, quietude, loss of muscular strength, with a decidedly 
ataxic gait, hebetude, stupor, and finally sleep. When death occurs, it 
is preceded by dyspnoea and general convulsions. Kohler is probably 
correct in attributing it to asphyxia. After these general considera¬ 
tions, we can probably best get an idea of the physiological action of 
the drug by studying its influence upon the various systems in detail. 

Circulation. —In regard to the action of salicylic acid upon the 
arterial pressure , observers are so much at variance as to leave the sub¬ 
ject enveloped in mystery. Kohler (Centralbl. f. Med. Wissensch ., 1876, 
pp. 163, 195) affirms that when salicylic acid or salicylate of sodium 
in solution is injected into the jugular vein, there is an immediate fall 
of blood-pressure, which after a large dose is very pronounced; in a 
short time the pressure rises to some extent, but not to the normal 
point, while the pulse-waves become excessively high and two- or three- 
peaked. As he found that the fall of pressure occurred after section 
of the depressors, the vagi, and the cervical cord, he very naturally 
concluded that it was due to an action upon the heart itself.* 

In 1879 ( These de Paris'), Hugues Oltremare found that moderate 
doses of salicylate of sodium increase the arterial pressure and the 
frequency of the pulse, while poisonous doses strongly depress the 
heart-force and the blood-pressure. In accord with this are the elabo¬ 
rate experiments of Danewsky ( Arbeiten d. Pharm. Labor at. Moshau , i. 
190). He found that at first the arterial pressure was increased, partly 
on account of an increase in the force and energy of the cardiac beat, 
but chiefly as the result of excitation of the vaso-motor centre. Vaso¬ 
motor spasm was shown to be the main factor in the rise of the blood- 
pressure, by the inability of the drug to increase the arterial pressui’e 
after section of the spinal cord. The action on the heart was seemingly 
direct. The arterial pressure slowly fell during the later stages of 
poisoning, the heart-stroke becoming weaker and weaker, and finally 
being extinguished. 

With our present evidence it appears probable that the fall of 
arterial pressure observed by Kohler was due to the use of very large 
doses, and that moderate doses have no depressing effect upon the cir¬ 
culation. Clinicians have, I think, generally come to the conclusion 
that the drug is depressant to the heart in man, and is not to be used 


* Professor S6e (Bulletin de I’Academie de MSdecine, 1877, p. 697) states that in his ex¬ 
periments there has been no action whatever upon the arterial pressure or the pulse-rate; 
but there is reason for believing that these negative results were reached because Professor 
See gave the acid by the mouth and studied the blood-pressure before the drug was absorbed, 
since Kohler found (loc. cit.) that injections of solutions of the acid into the stomachs of dogs 
and rabbits failed to affect the blood-pressure, although the sodium salt administered in a 
similar manner did depress the force of the circulation. 



614 


GENERAL REMEDIES. 


when cardiac weakness exists. This is, however, earnestly combated 
by E. Maragliano ( Zeitschrift f. Klin. Med., 1884, viii. 248), who has 
made a very large number of sphygmographic studies, and also a series 
of experiments with the sphygmomanometer of Baseh, and finds the 
arterial pressure usually elevated, and never depressed, by therapeutic 
doses of the drug. I believe that the general nervous depression which 
the drug produces when very largely given has been mistaken by 
clinicians for a cardiac depression; but it must be remembered that 
when administered continuously the salicylates probably accumulate in 
the system, and may reach the amount necessary to depress the heai’t. 

Nervous System .—Our knowledge of the action of the drug upon 
the nervous system is very imperfect. According to See, the violent 
convulsions that precede death are in the lower animals almost the 
sole evidences of disturbance of the nervous system,—the reflex 
power of the spinal cord, the general sensibility, and the conducting 
power of the nerve-trunks not being affected. M. Boc-hefontaine affirms, 
however ( Le Progres Med., 1877, p. 630), that in the frog the drug acts 
as a paralyzant, destroying the functional power of the spinal centres; 
while according to M. Laborde four grammes of a salicylate will pro¬ 
duce in the dog profound cutaneous anaesthesia (Ibid., 609). 

Pespiration. —In Kohler’s experiments upon rabbits and Danewsky’s 
experiments upon dogs, the respiration during the injection of the acid 
or its sodium salt into a jugular vein was decidedly quickened, but 
after a time the rate fell to much below the normal. When, in Kohler’s 
experiments, the pneumogastrics were divided during the period of re¬ 
tardation, the frequency of the respiration was still further lessened. 
Danewsky practised section of the vagi before exhibiting the drug and 
during the first stage of accelerated breathing. In the first instance 
he found that the breathing was only slightly accelerated by the drug ; 
in the second, that the quickened respiration fell to the same slowness 
that is seen in the unpoisoned animal with cut pneumogastrics. His 
experiments were too few to be conclusive, but indicate the correctness 
of his deduction that the quickening of respiration is largely due to 
an irritation of the pulmonary vagi, and not solely to an influence 
upon the respiratory centres. There is, however, probably some stimu¬ 
lation of the respiratory centres after small doses; but after very large 
doses fatal failure of respiration occurs through a gradual or sometimes 
sudden depression of the centres. 

Temperature. —Especial interest attaches to the action of salicylic 
acid upon the temperature. In Professor See’s experiments upon 
normal men and upon animals, very large doses (ten grammes for men) 
had no effect upon the temperature (loc. cit.). The experiments of 
Dr. Paul Fiirbringer upon rabbits, dogs, and men are in accord with 
this (Zur Wirkung des Salicylsaures, Jena, 1875). M. Gedl, in twelve 
seemingly very carefully conducted experiments upon man, in which 
the doses varied from forty-six to seventy-eight grains, found that the 


ANTIPYRETICS. 


615 


effect in three cases was various, in two cases negative, in three a lessen¬ 
ing of the daily alterations of temperature, in three a slight lowering 
of temperature, and in one a fall of 0.8° C. (Centralbl. f. Med. Wissens., 

1876, p. 403). Danewsky states that in normal animals and man the 
influence of the acid upon temperature is slight and inconstant. The 
evidence seems to show that salicylic acid, like quinine, has, in non-toxic 
doses, little or no decided action upon the temperature in health. In 
one or two experiments upon himself, Mr. North ( Practitioner , xxiii. 
184) found that the acid exerted a decided influence in preventing the 
rise of bodily temperature normally caused by exercise. 

Dr. Hobart A. Hare has reported ( Therap. Gaz., vol. iii. p. 450) a 
series of experiments made for the purpose of determining the in¬ 
fluence of salicylic acid upon the production and dissipation of animal 
heat. Unfortunately, however, the doses which he employed were not 
sufficiently large to produce positive results. Especially was this true 
in the experiments made upon animals suffering from fever. Indeed, 
there was not in those animals suffering from fever any fall of bodily 
temperature under the influence of the salicylic acid administered. To 
attempt to reason from the results reached as to the method of the 
action of salicylic acid when it does cause fall in bodily temperature 
seems to me futile. 

The first effect of a single antipyretic dose in fever is usually a pro¬ 
fuse sweat, which may appear fifteen minutes after the ingestion of 
the remedy (Ewald, Practitioner , xvi. 200). V ery shortly after this 
the temperature begins to fall, and, according to Justi (Centralbl. f. Chi- 
rurgie , 1876, p. 629), the depression reaches its maximum in about six 
hours. The sweating is profuse and exhausting, amounting, according 
to Ewald, not rarely to seven hundred and fifty grammes. The per¬ 
spiration can scarcely be the only factor in the reduction of tempera¬ 
ture, as there appears to be no relation between its amount and the 
degree of the fall, and it usually ceases before the latter reaches its 
maximum. 

The statements in regard to the action on the pulse in fever vary so 
much as to suggest that when any decided lessening of the cardiac 
beat does occur, it is dependent upon the fall of temperature. Thus, 
Garcin ( Journ. de Therap ., 1876, p. 25), Oulmont ( Le Progres Med., 

1877, p. 587), and Moeli ( Deutsches Archiv , xvii. 592) have all observed 
the pulse-rate to fall with the fever-heat, while L. Schroeder affirms 
that after moderate doses the pulse is slackened, after large ones quick¬ 
ened, and Ewald and other observers state that it is usually not affected. 
The antipyretic dose employed varies somewhat. Ewald gives as a 
minimum to the adult seventy-five grains, repeated in five hours if 
necessary; Justi, from ninety to one hundred and twenty-five grains. 

Absorption and Elimination. —Salicylic acid appears to be absorbed 
very rapidly. Drasche (Centralbl. f. Chir., 1876, p. 777) affirms that it is 
only necessary to apply its alcoholic solution to the sound skin for a 


616 


GENERAL REMEDIES. 


short period, in order to find the drug in the urine. Owing to the in¬ 
solubility of salicylic acid, the problem of the method of its absorption 
and of the state in which it circulates in the blood early attracted atten¬ 
tion. Salkowski ( Berlin. Klin. Wochenschr., 1875, p. 297) pointed out 
that the acid in the blood probably exists in the form of a salicylate of 
sodium. Professor Binz supposes ( Lond. Pract., xxvi. 443) that the 
acid is liberated in the blood by the carbonic acid formed in the tissues. 
The only basis for this theory consists in the fact that by passing car¬ 
bonic acid gas through a solution of phosphate, carbonate, and sali¬ 
cylate of sodium, agitating with ether, and separating and evaporating 
the latter, crystals of salicylic acid are obtained. It is evident that if 
in the blood changes take place similar to those which occur in this 
solution, salicylic acid should be yielded to ether shaken with the blood 
of an animal poisoned with the drug. Feser and Friedeberger found 
that unless enormous doses of the drug were injected into the blood, so 
as to produce immediate violent convulsions and death, the vital fluid 
of the poisoned animal yielded nothing to ether. In Kohler’s experi¬ 
ments ( Centralbl. f. Med. Wissens., 1876, p. 553), when salicylic acid was 
dissolved in normal blood no acid was yielded to ether, but when the 
blood of asphyxia— i.e., blood supersaturated with carbonic acid—was 
employed, a very notable amount of the acid was extracted by the 
ether. These experiments seem to me to warrant the conclusion that 
when the blood is in the normal condition the alkaline salicylates are 
not decomposed by the carbonic acid in it. 

Feser and Friedeberger (loc. cit .) have advanced the theory that the 
salicylic acid circulates in the form of an albuminate. This has re¬ 
ceived some support from the experiments of Farsky ( Sitzb. d. k. Alcad. 
d. Wissens., lxxiv., Bd. ii.), which seem to show that the acid is capable 
of forming such a compound.* On the other hand, the theory is contra¬ 
dicted by the results of Fleischer (Med. Centralbl ., 1876, p. 628), who 
digested albuminous solutions with the acid, and after coagulation by 
heat found all the acid in the filtrate, and who also treated the blood 
of poisoned animals in a similar way, and found the salicylic acid only 
in the serum, the coagulum being free. 

Viewing all this evidence together, it seems a probable conclusion 
that salicylates, when administered internally, enter the vital fluid and 
circulate there as salicylates, and that salicylic acid itself is probably 
converted by the alkaline juices of the alimentary canal into a salt, and 
as such enters the system and exerts its influence on the organism. 

Salicylic acid escapes from the body chiefly through the kidneys, f 


* He digested various albuminous substances with salicylic acid, washed them with ether 
until it would take no more acid, dried, washed with water, and found on analysis salicylic 
acid largely present in the residue. 

f To detect salicylic acid in the urine, add the solution of chloride of iron carefully. At 
first white phosphate of iron precipitates, then, if the acid be present, a violet color is pro¬ 
duced (Kolbe). 



ANTIPYRETICS. 


G17 


F iirbringer and Drasche ( Centralbl.f. Chir., 1876, 777) failed to detect it in 
the faeces, the saliva, the bronchial secretion, or the sweat, but M. Mussy 
found it in the saliva (Bull. Therap ., xiii. 318), as did also M. Balz; 
and M. Oulmont detected it in the serosity of a blister. It appears in 
the urine very soon after its ingestion, but its elimination proceeds 
slowly. Thus, in a case of exstrophy of the bladder it was detected 
in the urine dripping from the ureters eight and a half minutes after 
its ingestion (Balz, Arch. d. Heilk., xviii. 60), and it has been found in 
the urine eight days after the exhibition of the last dose (Byanow, 
Centralbl. f. Chirurg., 1877, p. 809). The latter obser ver also found it in 
the urine of a normal man as a salicylate twenty-five minutes after its 
swallowing. The same authority states that it is excreted partly as 
salicyluric acid,* partly as a form of salicin, and, he believes, to some 
extent as oxalic, acid. Urine which had been passed some hours after 
the ingestion of a dose polarized to the left. Dr. A. E. Stuart ( Prac¬ 
titioner , xviii. 425), after so small a dose as nine grains of the acid, 
saw free, distinct crystals of salicyluric acid in the urine. It is pos¬ 
sible that such of the salicylic acid as escapes unchanged from the 
kidney may, as first excreted, be in the form of a salicylate, but be set 
free by the phosphoric acid of the urine; at least such would be indi¬ 
cated by the fact that in Balz’s case of exstrophy salicylate of sodium 
appeared in the urine twelve minutes before the free acid. The green 
color of the urine characteristic of the free use of salicylic acid ap¬ 
pears to be due to an increase in the formation of indican (S. Wolf- 
berg, Deutsches Archiv f. Klin. Med ., xv. 403; M. Bobin, London Med. 
Record , 1877, p. 151), or else to pyrocatechin (see Bull. Acad. Med., 
1877, p. 705), and it is not improbable that the pyrocatechin is formed 
out of the salicylic acid. The urine itself is often augmented in quan¬ 
tity, but sometimes it is diminished. It not rarely contains albumen, 
evidently the product of a local irritation of the kidneys. See reports 
(loc. cit., p. 705) a case in which the renal irritation was so severe as to 
give rise to hsematuria. In regard to the solids of the urine, the testi¬ 
mony varies somewhat. See (Joe. cit.) affirms that in gout the uric acid 
is greatly increased, and that both in health and in disease the urea 
is unaffected. S. Wolfsohn ( Inaug. Diss., quoted in Centralbl. f. Med. 
Wissens., 1877, p. 30), on the other hand, determined an increase in 
the nitrogenous renal elimination, while Lecorche and Salamon have 
found that when the acid is exhibited in rheumatism there is at first 
an enormous increase in the excretion of both urea and uric acid, fol¬ 
lowed by diminution, which may carry the elimination below the nor¬ 
mal. In acute rheumatism the first increase lasts three or four days, 
in subacute rheumatism one or two days ; excretion of phosphoric acid 
is also at first increased and subsequently lessened. In experiments 


* Salicyluric acid is a parallel compound to hippurio acid, made by the union of the ele¬ 
ments of a glycocol with salicylic acid. 



618 


GENERAL REMEDIES. 


upon dogs Carl Virchow found that the nitrogenous elimination was 
increased by salicylate of sodium (Zeitschr. f. Physiol. Chem., vi. 78). 

Summary .—In full doses salicylic acid causes symptoms resembling 
those produced by quinine, but after larger doses there are mydriasis, 
marked disturbance of respiration, great nervous prostration, delirium, 
dyspnoea, and, if the dose has been large enough, death by respiratory 
paralysis. Moderate therapeutic doses appear to have no powerful 
influence upon the circulation, such physiological evidence as we have 
indicating that they increase arterial pressure somewhat by exciting 
the vaso-motor centre and directly increasing the cardiac force. In 
overdoses salicylic acid causes fall of the arterial pressure, partly by a 
direct action upon the heart. Our knowledge of the action of the acid 
upon the nervous system is very imperfect, but it seems to be a de¬ 
pressant of the motor nervous centres. Moderate doses increase the 
frequency of the respiration, probably in part by an action upon the 
peripheral pneumogastrics, but chiefly by a direct influence upon the 
respiratory centres. Toxic doses paralyze the respiratory centres. The 
action of salicylic acid upon the temperature of normal man is slight 
and inconstant, unless toxic doses be given; in fever its antipyretic 
influence is pronounced, but we have no exact knowledge as to the 
method of its action. It is absorbed and circulates in the blood prob¬ 
ably as a salicylate of sodium, and is eliminated partly unchanged as a 
salicylate, partly as salicyluric acid, the green discoloration of the 
urine being due to indican, or perhaps to pyrocatechin, which may be 
an educt from the acid. The exact effect upon elimination of urinary 
solids is not positively determined; it probably increases nitrogenous 
elimination: large doses irritate the kidneys. 

Therapeutics. —The original article of Dr. E. Butt upon the action 
of salicylic acid upon temperature in fever has been followed by a 
number of papers (see London Med. Record , 1876, p. 193*), which 
show that the drug fails in some cases to reduce temperature, but 
seems to be more certain and decided in its effects than is quinine. 
The question as to whether good is achieved in fevers by its admin¬ 
istration is, of course, entirely separate from that as to its power 
of reducing temperature. It is certainly possible for a drug to lower 
the fever-heat and yet to do far more harm than good, and the evi¬ 
dence at hand does not yet seem sufficient to answer the present in¬ 
quiry. In the Semenoff’schen Military Hospital, from January, 1875, 
to the middle of September, 1875, two hundred and eleven cases of 
typhoid (?) fever were treated without salicylic acid, and from the last 
date to March, 1876, one hundred and sixty cases with the acid. The 


* Consult also Deutsches Archiv f. Klin. Med., 1876, xv. 457, 518, 612, xvi. 162, xvii. 294, 
314, 607, 692, xviii. 401, 452,504; Centralbl. f. Med. Wissensch., 1876, xci. 198; Lanoet, 1877, 
ii. 812; Practitioner, xvi. 200; Lond. Medical Record, 1877; Berlin. Klin. Wochenschrift, 
1875, 693; Le Progres Med., 1877; Bulletin Acad. Med., 1877. For information in regard to 
its action on pyaemic rabbits, see Fiirbringer, loc. cit. 




ANTIPYRETICS. 


619 


mortality in the first period was 14.7 per cent., in the last 19.4 per cent. 
(Schroeder, Deutsches Archiv f. Klin. Med., xviii. 516). In the garrison 
of Stargard, in 1872, thirty-nine cases received mild cold-water treat¬ 
ment; in 1874, sixty-three cases, cold-water treatment energetically; 
in 1875, thirty-five cases, the salicylic acid treatment; the mortality 
being, respectively, 30.7, 9.5, and 8.5 per cent., and the average length 
of treatment 66.6, 53.3, and 37 days (Jahn, Ibid., p. 451). Riess treated 
two hundred and sixty cases of typhoid fever, and lost 24.2 per cent. 
(Berlin. Klin. Wochens., xii. 675). He asserts that the duration of the 
disease was very much shortened. These statistics are all that I have 
been able to glean upon the subject, and apparently leave the question 
at issue sub judice. The superiority of antipyrin and antifebrin has 
since their discovery led to the complete abandonment of the use of 
salicylic acid in fevers. 

The antiperiodic action of the drug does not appear to be such as to 
entitle it to confidence. It is true that Senator in nine cases of inter¬ 
mittent fever had but one failure ( Berlin. Klin. Wochens., 1875) ; but the 
general drift of experience coincides, I think, with that of Helley, 
who found salicylic acid to fail in obstinate malarial cases, and in mild 
cases to require longer time to cui’e than does quinine. 

The antipyretic properties of salicylic acid early led to its being 
used in rheumatism * and in 1876 ( Berlin. Klin. Wochens., xiii.) Strieker 
first announced that it was an exceedingly valuable remedy in this dis¬ 
ease, usually, when given in hourly doses of from seven to fifteen grains, 
causing a disappearance of the symptoms in a period not exceeding 
forty-eight hours. The conclusions of Strieker have been substan¬ 
tially confirmed by numerous observers in German}’, France, England, 
and this country. Although some cases of rheumatism do not seem to 
yield to the drug, in the great majority of instances improvement sets 
in within twenty-four hours, and is rapidly followed by disappearance 
of the pain and fever. The dangers of cardiac and cerebral complica¬ 
tions are certainly lessened, but not altogether done away with.f In 
excessive rheumatic hyperpyrexia it cannot be depended upon to the ex¬ 
clusion of the cold bath. Jaccoud states ( Progres Med., 1877, pp. 528, 
745) that he has found it of great service in chronic rheumatism ; but the 
general testimony appears to show that it is less certain in the chronic 
than in the acute disorder. Jaccoud also states that in acute gout it 
acts with extraordinary effect. As in cases of habitual gout the kidneys 
are often seriously affected, the urine should always be examined, and 
if it be found albuminous the remedy should be administered very 
cautiously. Dr. II. Weber has seen the salicylates act most happily in 
gonorrhoeal rheumatism (Bull. Therap., xeiii. 328). Various mishaps 


* E. Buss was probably the first to make trial of this remedy. 

Consult for this point Jaccoud (Le Progrit Med., 1877, p. 588), Green (London Lancet, 
Nov. 11, 1877), Roe ( Lancet , 1877, ii. 905), Jacobs (Ibid., 655), Brown (Boston Med. and 
Surg. Journ., Feb. 8, 1877). 



620 


GENERAL REMEDIES. 


(gangrene, Bull. Therap., xciii. 324; necrosis, Brit. Med. Journ., 1876, pp. 
2, 776, 820, 843) have been ascribed to the use of the acid in rheu¬ 
matism, but these were in all probability accidental complications of 
the disorder. Delirium and temporary insanity, sometimes erotic, have 
been in various cases, perhaps correctly, attributed to the acid {New 
York Med. Record , xxi. 456; London Med. Record , 1882, 452). 

Salicylic acid was at one time highly commended in diphtheria , but 
its use has been generally abandoned, and although in chronic cystitis 
and chronic pyelitis it is still sometimes employed, other remedies seem 
to be of more service. 

Administration.— The maximum dose of salicylic acid in acute 
rheumatism may he set down as a drachm in the twenty-four hours, 
although it is employed by some practitioners in much larger doses. 
The salicylate of sodium (Sodii Salicylas, U.S.) contains forty-eight 
grains of the acid to the drachm: since it is freely soluble in water, 
and is less unpleasant to the taste and less irritant to the stomach, it is 
much preferable to the uncombined acid. From sixty to eighty grains 
of it may be administered in the course of the day in a strongly aroma¬ 
tized syrup. The best method of exhibiting salicylic acid is either 
in the form of the oil of gaultheria (see p. 622), or in that of the 
salicylate of ammonium. This may be extemporaneously prepared by 
taking one drachm of salicylic acid and five drachms of syrup and 
adding aqua ammoniae in sufficient quantity to dissolve the acid. The 
finished product will be about six drachms, and one teaspoonful will 
represent ten grains of the acid. If during the use of any preparation 
of salicylic acid ringing of the ears or other evidences of intoxication 
appear, the remedy should be at once partly or entirely withdrawn. 

Use as an Antiseptic. —Salicylic acid was originally brought to the 
notice of the profession on account of its inhibitory influence on putre- 
faction. Kolbe found that 0.04 per cent, had great influence in prevent¬ 
ing souring of milk. Bucholz states that 0.15 per cent, is sufficient to 
prevent the development of bacteria in ordinary organic mixtures, and 
that the influence of 0.005 per cent, is plainly visible; 0.3 to 0.4 per cent, 
of the acid killed bacteria in vigorous growth {Arch. f. Exper. Path. u. 
Pharm., Bd. iv.). The salicylate of sodium was about equal to the pure 
acid, 0.4 per cent, destroying the bacteria.* In the preservation of urine, 
Meyer and Kolbe found that one part of salicjdic acid to two thousand 
parts of urine was sufficient to prevent putrefaction {Journ. f. Prakt. 
Chem ., Bd. xii.). According to Kolbe and others, salicjdic acid arrests 
or prevents the action of the non-organized organic ferments. Thus, 
it will inhibit the action of emulsin upon amygdalin or upon myronic 
acid, and prevent the development of hydrocyanic acid or of the vola¬ 
tile oil of mustard. Dr. Miller found that one per cent, of salicylic 


* The power of the acid has been denied by Fleck ( Benzoesaure , etc., Munich, 1875), who 
has been abundantly answered by Professor Kolbe {Journ. fur Prakt. Gliem., Bd. xii.). 



ANTIPYRETICS. 


621 


acid was sufficient to check the action of ptyaline upon starch; for the 
same effect ten per cent, of carbolic acid was required. The digestive 
action of pepsin, outside of the body, was very seriously affected by 
0.2 per cent, of salicylic acid in Dr. Miller’s studies, but in Kolbe’s 
experiments the ingestion of twenty grains a day of the drug had no 
effect. 

Salicylic acid has been used to a considerable extent in the prepa¬ 
ration of beer and wine, and for the preservation of various articles 
of food. On the 7th of February, 1881, the French government inter¬ 
dicted this use, and in 1885 a commission appointed by the Academy 
of Medicine of Paris, at the suggestion of the Minister of Agricul¬ 
ture, reported (Bull. Acad. Med., vol. xvi., 1886) that it is proved that 
the prolonged employment of even very small amounts of salicylic 
acid is dangerous, and that in susceptible individuals, and especially 
in aged persons, it is apt to cause disorder of digestion and disease 
of the kidneys. 

There can be no doubt that salicylic acid is capable of accomplish¬ 
ing much in antiseptic surgery, but it does not seem to be replacing 
carbolic acid, as it at one time bade fair to do. Its freedom from odor 
and comparative freedom from poisonous and irritant properties are 
certainly strong points in its favor: nevertheless, carbolic acid is more 
generally employed, and Mr. Callender, after twelve months’ trial in 
the wards of St. Bartholomew’s Hospital, has formally condemned 
salicylic acid as much inferior to carbolic acid (Trans. London Clin. 
Soc., ix.). Thiersch’s salicylic acid wadding for hermetically sealing 
wounds is made by dissolving two ounces of the acid in two pints of 
alcohol (sp. gr. 0.83), diluting with twenty pints of water at 158° to 
178° F., saturating with this six pounds and eight ounces of cotton 
batting deprived of oily matter, and afterwards drying. This wadding 
contains three per cent, of the acid; for some purposes a stronger 
batting, containing ten per cent., is prepared. When the wound or 
abscess is discharging profusely, jute is substituted for the cotton 
batting, because it is much more permeable to pus. An efficient oint¬ 
ment may be prepared by dissolving one and a half parts of the acid 
in two parts of alcohol and adding lard, or the solubility of the drug 
in glycerin may be taken advantage of. 

The following solutions are used in St. Bartholomew’s Hospital: 
Phosphate of sodium, three parts; salicylic acid, one part; water, fifty 
parts.—Salicylic acid, one part; olive oil, forty-nine parts.—Salicylic 
acid, one part; bicarbonate of sodium, half part; water, one hundred 
parts.—Salicylic acid, ten parts; borax, eighteen parts; water, one 
hundred parts. A twenty-five-per-ccnt. solution, which will bear dilu¬ 
tion with water or alcohol, may be prepared according to the follow¬ 
ing formula: R Acid, salicyl., 5h J Sodii biborat., 5i; Glycerin®, q. s. 
Mix the acid and the borax with four fluidrachms of glycerin ; heat 
gently until dissolved; then add enough glycerin to make one fluid- 


622 


GENERAL REMEDIES. 


ounce. Professor Thiersch has found that the drug cannot be employed 
for cleaning surgical instruments, because it corrodes the steel. 

OLEUM GAULTHERLE—OIL OF GAULTHERIA. U.S. 

Oil of gaultheria is a very volatile, slightly straw-colored liquid, of 
a penetrating peculiar odor, ninety per cent, of which is methyl sali¬ 
cylate, a substitution-compound in which one atom of the hydrogen of 
salicylic acid has been replaced by a molecule of methyl, CH S . The 

formula of salicylic acid is C 7 II 6 0 3 ; of methyl salicylate, C 7 j j 0 3 . 

When oil of gaultheria is taken into the animal system, one atom 
of carbon and two atoms of hydrogen in the methyl are removed 

cif, 

atomic weight of 152, while the atomic weight of C 7 H 6 O s is 138: so 
that the administration of one hundred and fifty-two grains of methyl 
salicylate ought to be equivalent to the giving of one hundred and 
thirty-eight grains of salicylic acid. As one hundred and sixty-nine 
grains of oil of gaultheria contain one hundred and fifty-two grains of 
methyl salicylate, they should be equivalent to one hundred and thirty- 
eight grains of salicylic acid. 

When oil of gaultheria is taken in sufficient dose, it causes symp¬ 
toms which are entirely similar to those that are produced by cor¬ 
responding doses of salicylic acid. It has produced severe or even 
fatal poisoning: thus ( Phila . Med. Examiner , June, 1852), Dr. Gallaher 
reports the recovery of a boy of nine years after the ingestion of half 
an ounce, but Dr. Juvet reports ( N . Y. Med. Gaz., 1867) a case in which 
half an ounce of the oil of wintergreen caused death. Recovery after 
large doses of the drug is often attributable to the vomiting which has 
been produced by the irritant action of the oil. According to the ex¬ 
periments of Drs. H. C. Wood and Hobart A. Hare ( Therap. Gaz., 1886, 
73), the physiological action of gaultheria is the same as that of sali¬ 
cylic acid, therapeutic doses being entirely decomposed in the system, 
although toxic amounts may escape in part unchanged. 

Oil of gaultheria affords a very excellent method of giving salicylic 
acid in cases of subacute and acute rheumatism. It may be admin¬ 
istered in emulsion or in capsules in doses of from ten to fifteen minims, 
repeated according to circumstances. I have given as high as one hun¬ 
dred and fifty drops of it in twenty-four hours, though few persons will 
bear more than half this amount without the production of distinct 
symptoms, which should be a signal for withdrawal. 

SALICINUM—SALICIN. U.S. 

Salicin is obtained from the bark of the willow and other trees. It 
occurs sometimes in tabular crystals, more frequently in white, shining 
needles, of neutral reaction, soluble in about thirty parts of cold water, 


by oxidation, and C 7 j 


O s becomes C 7 H 6 0 3 . 


C, 




O, has an 


ANTIPYRETICS. 


623 


very soluble in hot water and in alkaline solutions. Concentrated sul¬ 
phuric acid dissolves it, with the production of a beautiful red color. 
By carefully warming it with dilute sulphuric acid it is converted into 
glucose and saligenin, and it is therefore a glucoside. 

The action of salicin upon the animal organism is not known, but 
would seem to be very feeble, as Ranke ( Pflanzenstoffe , p. 903) is said 
to have taken nearly three ounces of it without any notable effect. It 
is certainly rapidly absorbed, probably as salicin; but once in the blood 
it seems to be quickly decomposed, the products of its change appear¬ 
ing in the urine fifteen to thirty minutes after the ingestion of a single 
dose. This change does not appear to be complete, as, according to 
Husemann ( Pflanzenstoffe , 963), in the urine of man and rabbits after 
the ingestion of salicin not only saligenin and salicylic acid occur, 
but also unchanged salicin. Further, Falck, injecting salicin into the 
blood of the dog, found that it chiefly escaped from the kidneys un¬ 
altered. The elimination seems to go on slowly, as Senator has detected 
salicylic acid in the urine sixty hours after the ingestion of a single 
dose of salicin ( Berlin. Klin. Wochens ., 1877, 181). 

In 1874, Dr. Maclagan, led by some fancied dependence of rheu¬ 
matism upon malaria, began the use of salicin in acute rheumatism, 
and in 1876 ( Lancet , 1876, i. 342) he announced that it was a specific 
remedy, rapidly abating both the fever and the local symptoms. In 
the same year ( Centralbl. f. Med. Wissens ., 1876, 241; also Berlin. Klin. 
Wochens., 1877, 181) H. Senator confirmed these statements, and fur¬ 
ther affirmed that in various affections he had found salicin to have an 
antipyretic power entirely comparable to that of salicylic acid. If 
these views are correct, the freedom from irritant properties and dis¬ 
agreeable taste make salicin superior to the acid. The only other per¬ 
son who has tested the matter on a considerable scale is Dr. Buss, who 
does not find that the drug is nearly so powerful as salicylic acid (^Ber¬ 
lin. Klin. Wochens., xiii. 504). If, as is believed by Senator, the activity 
of salicin depends upon its conversion in the blood into salicylic acid, 
it is plain that its action should be slower and more uncertain than that 
of the acid.* Further investigations are necessary before a positive 
conclusion can be reached; but the later evidence does not seem to be 
favorable to salicin, and it is but little used. In regard to the dose em¬ 
ployed, it is worthy of remark that no serious symptoms have been re¬ 
ported as produced by salicin. Senator recommends two to two and a 
half drachms as a moderate dose for the adult. Maclagan used much 
smaller doses,—twenty grains every three hours, f 


•» Dr. Maclagan asserts (London Lancet, 1872, ii. 179), as proof that salicin does not act as 
salicylic acid, but as salicin, that he has given salicin to rheumatic patients suffering from 
cerebral symptoms due to large doses of salicylic acid, and has seen both the rheumatism and 
the cerebral disturbance abated. Is it possible that the delirium in these cases was due to 
rheumatic irritation, and not to the salicylates? 

-j- Consult also Brit. Med. Journ., 1876, ii., and Boston Med. and Surg. Journ., Feb. 1877. 



624 


GENERAL REMEDIES. 


Salol is a white crystalline powder, of a faintly aromatic odor 
resembling that of oil of wintergreen, almost insoluble in water, and 
perfectly tasteless. It is a derivative of salicylic acid, one atom of the 
hydrogen of the acid having been replaced by phenol. It belongs to 
the aromatic ethers, and may be considered chemically as a salicylate 
of phenol. Originally prepared by Professor Yon Hencki, of Berne, 
it was introduced into medicine by M. Sahli ( Science Med., April 14, 
1886). When in the upper part of the intestinal tract it comes in con¬ 
tact with the pancreatic juice it is broken up into its original constitu¬ 
ents, salicylic acid and phenol, yielding about thirty-six per cent, of 
phenol and sixty-four per cent, of salicylic acid.* After its free use 
the urine becomes black from the products of destruction of carbolic 
acid, and it is capable of causing the symptoms of poisoning by sali¬ 
cylic acid and by carbolic acid, but is said to be less powerful as a poison 
than are its ununited ingredients, probably because it is broken up 
slowly and perhaps escapes in part unchanged. 

The therapeutic properties of salol are those of salicylic acid, and a 
number of clinicians have reported veiy favorable results from its use 
in rheumatism. (See Drs. Bielschowsky, Georgi, Rosenberg, and Feil- 
chenfeld, Therap. Monatsh., 1887; also Land. Med. Bee., Oct. 15, 1886, 
June 15, 1887, Jan. 15, 1887; also Berlin. Klin. Wochens., Ho. 4, 1887, 
and others.) By the use of salol the ringing in the ears and other 
ordinary constitutional symptoms produced by salicylic acid can be 
obtained, and there is no doubt that the drug is capable of perforrhing 
in rheumatism the role of salicylic acid. The claim that it is incapable 
of producing untoward symptoms and that it agrees better with the 
stomach than do other salicylic preparations is doubtfully sustained. 
It is, however, less disagreeable to take than some other forms of the 
acid, but in my experience has been less prompt and less certain in its 
influence. It has been used as a disinfectant for the bowels in typhoid 
fever and cholera, etc., also for the treatment of catarrh of the bladder 
and in diabetes. To some extent it has been employed by surgeons as 
an antiseptic in the place of iodoform. According to German authori¬ 
ties, the full dose of salol is half a drachm three times a day. This is, 
however, a very large dose, not more than half of which should be 
ordinarily given. 

Bethol of Sahli, or Naphtholol of Robert, is the salicylate of /9-naph- 
thol ether, and occurs in small, white, resplendent, almost tasteless 

* Professor Ewald affirms, as the result of experimental research, that salol is not decom¬ 
posed in the stomach, hut immediately upon its entrance into the intestines, and that the 
products of decomposition appear almost at once in the urine in the form of salicylurio acid, 
which yields a red precipitate with chloride of iron. Ewald proposes taking advantage of 
this fact in order to determine the rate at which food passes from the stomach. The urine 
of seven persons in sound health afforded the salicyluric acid reaction in from one-half to three- 
quarters of an hour after the ingestion of the drug, but in seven cases of gastric dilatation 
with weakness of the muscular coat of the stomach two to three hours were required. 



ANTIPYRETICS. 


625 


crystals, insoluble in water, but soluble in alcohol and in fats, and 
having a melting-point of 203° F. It has been introduced to the pro¬ 
fession by Merck, and studied to some extent by Ivobert and B. II. 
Sahli ( Therap. Monatshefte , 1887, v. and vi.). It is a compound analo¬ 
gous to salol, but having the base of naphthol instead of phenol, and 
consequently splitting up under the influence of the intestinal juices 
into salicylic acid and naphthol. It contains ten per cent, less salicylic 
acid than does salol, and has the further disadvantage of possessing a 
much higher melting-point and therefore splitting up less readily into its 
component parts. Ivobert claims for it that it is preferable to salol in 
rheumatism, as producing less disagreeable after-effects, but Sahli be¬ 
lieves that it is not so certain in its action. On account of its not yield¬ 
ing phenol, it is less poisonous than salol. Kobert has found that when 
given internally it is very useful in the treatment of catarrh of the 
bladder , as well as of gonorrhoeal cystitis. 

ANTIPYRIN. 

This is a substance discovered by Dr. Ludwig Ivnorr, of Munich, 
and first experimented with by Professor Filebne, of Erlangen ( Zeit - 
schrift f. Klin. Med., 1884, vii. 641). It is a grayish or reddish-white 
crystalline powder, of a slightly bitter taste, soluble in fifty parts of 
ether, much more so in water, ten parts of it being dissolved in six 
parts of cold water, and also very soluble in alcohol and chloroform. 
Its solution strikes with a solution of perehloride of iron a reddish- 
brown color, with nitric acid a beautiful greenish color. Chemically, it 
is dimethyloxyquinizine. It is prepared by an extremely complicated 
(patented) process. Mr. James Kennedy (. Pharrn . Rec., Dec. 15, 1885) 
has found that antipyrin is incompatible with sweet spirit of nitre, tho 
solution gradually turning green, and depositing beautiful green crys¬ 
tals of a new compound. 

Physiological Action.— According to the observations of Dr. Leon 
Arduin ( Thesis, Paris, 132, 1885), of Professor Demme (. Fortschritte der 
Medicin, 1884, ii. 657), and of Dr. Coppola ( Robert's Jahresbericht, 
1885, p. 314), antipyrin produces in frogs, when given in very large 
doses, complete relaxation, with loss of reflex action, and death. In 
moderate toxic doses (half to one centigramme) it causes convulsions, 
with opisthotonos, and a very marked increase of reflex activity. In 
the earlier stages of this condition the animal is cataleptic. The 
symptoms which are caused in the higher animals by antipyrin are 
similar to those which it produces in frogs. 

Nervous System. —Coppola affirms that the convulsions are at least in 
part due to an action upon the brain, and are arrested by section of the 
spinal cord. This conforms with the statements of Chouppe ( Semaine 
Med., July, 1887), that the convulsions of antipyrin do not produce 
cramp-asphyxia, and that the drug even has the power of suspending 
the strychnic convulsions. According to Lepine ( Lyon Med., vol. liii.), 

40 


626 


GENERAL REMEDIES. 


antipyrin has some influence upon the motor nerves; and if access to 
a nerve be shut off by the previous tying of an artery, such nerve after 
death from antipyrin is distinctly more active in its response to stimuli 
than is the nerve of the opposite leg. It does not, however, appear 
probable that the loss of reflex activity which has been noted by 
Lepine, as well as by other observers, is the result of the slight influ¬ 
ence which the drug has upon the motor-nerve trunks. Various ob¬ 
servers have noticed during life more or less pronounced muscular stiff¬ 
ness ; and Devraux-Armand has seen it pass into post-mortem rigidity 
in animals fatally poisoned ( Thesis , Nancy, 1885). This stiffness 
appears to be the result of an action exerted directly upon the mus¬ 
cles ; for in Armand’s researches the muscles removed from the body 
of the animal killed with antipyrin underwent much more powerful 
and prolonged contraction than was produced by the same amount of 
stimulation in the normal muscle. Coppola affirms that antipyrin has 
a slight and temporary influence upon the sensory nerves , and at the 
place of injection sensibility is lessened for some minutes. The pupils 
are also constantly dilated by it. 

Circulation. —Further researches in regard to the action of antipyrin 
upon the circulation are very desirable, but there are certain points 
concerning which we have definite knowledge. Arduin, Demme, Le¬ 
pine, and Armand all affirm that in the poisoned frog the heart is 
arrested in diastole, but Coppola states that antipyrin has no influence 
upon the circulation in the frog, that in many eases after the largest 
dose the heart is arrested in systole, and that in the Williams apparatus 
no effect is produced by antipyrin upon the isolated heart unless the 
dose be enormous. Notwithstanding the statements of Coppola, I think 
it must be considered established that in sufficient dose antipyrin acts as 
a direct paralyzant to the frog’s heart. Demme, Arduin, Armand, and 
Henry Casimir ( Thesis , Lyons, 1886) have separately determined by 
experiment that in moderate doses antipyrin increases the arterial press¬ 
ure , while toxic doses lower the pressure. The exact method in which 
antipyrin acts in producing these changes in the circulation has not 
been determined. Querrolo, employing the plessimograph of Mosso 
(quoted by Armand), found that the arm is increased in size under the 
influence of antipyrin, and therefore that the peripheral vessels are 
dilated, and Casimir affirms that similar dilatation can be seen in the 
blood-vessels of the ears of rabbits poisoned by antipyrin. Even if 
these results be correct, we do not know whether the dilatation is pro¬ 
duced directly or indirectly. That the rise of the arterial pressure is 
at least in part the result of a vaso-motor spasm is indicated, although 
not proved, by the fact ascertained by Casimir, that it is accompanied 
by a distinct decrease in the size of such vascular internal organs as 
the kidney. That the rise is not due to asphyxia is proved by its oc¬ 
currence in curarized animals. The theory that the rise of pressure is 
in part at least due to contraction of the vessels is corroborated by the 


ANTIPYRE TICS. 


627 


assertion of Arduin, that antipyrin is a powerful haemostatic, acting like 
ergot. Huchard and Henocque (as quoted by Armand) reiterate the 
power of the drug in arresting hemorrhage, and state that, when they 
cut off the feet of guinea-pigs and put the stumps into a solution of 
antipyrin, tincture of chloride of iron, etc., the bleeding was arrested most 
quickly by the antipyrin. AVhen the drug is given very freely to man 
it produces a peculiar livid color of the face, especially marked in the 
lips, which is due to an alteration in the blood-color itself. According 
to the researches of Lepine, the change is the result of the production 
in the blood of methsemoglobin. In Lepine’s experiments it was shown 
by counting that the blood contained before, during, and after antipyrin- 
intoxication the same number of the red blood-corpuscles, which there¬ 
fore are not destroyed by antipyrin. 

Respiration. —The respiration is not affected by therapeutic doses of 
antipyrin, but after toxic doses it progressively diminishes. 

Absorption and Elimination. —Antipyrin is freely absorbed and as 
freely eliminated by the kidneys. Armand affirms that it appears in 
the urine from twenty-five to thirty minutes after its ingestion and 
continues for thirty-six hours, although most of it is eliminated in the 
first twelve hours. Maragliano ( Robert's Jahresb ., 1885, p. 313) states 
that it appears in the urine three hours after its ingestion, and that the 
elimination is at its height in four hours and continues for a day to a 
day and a half. He states that it can readily be recognized by render¬ 
ing the urine acid and adding an iodized solution of iodide of potassium, 
when a reddish-brown color develops. The urine is sometimes increased 
in quantity, and sometimes diminished, especially when free sweating is 
produced. It is normal in appearance, and never contains albumen or 
sugar. I. I. Hage ( Robert's Jahresb ., 1885, p. 316) failed to detect anti- 
pyrin in the sweat or the saliva. 

Temperature. —When given in large doses to the normal animal, 
antipyrin frequently, but not invariably, produces fall in the bodily tem¬ 
perature ; in the fevered animal the fall of temperature is more marked 
and more constant. The cause of the fall cannot be considered to be 
entirely established, but it is probably the result of an influence exerted 
direct^ upon the thermogenetic centres. It is certainly independent 
of any action upon the general circulation, as I have seen the tempera¬ 
ture reduced four or five degrees by antipyrin without any distinct 
change in the arterial pressure. In seven out of nine experiments made 
by Drs. II. C. Wood, E. T. Eeichert, and Hobart A. Hare* ( Therap. Gaz ., 
ii. 803) upon normal animals, there was a decrease in both the produc¬ 
es The course of fever produced by injections of pepsin in the blood varies, and in calo¬ 
rimetric experiments it is not sufficient to give pepsin and when the temperature has risen 
administer the antipyretic and study calorimetrically the result. The best way is to produce 
a paroxysm of fever on one day and study it calorimetrically through its whole course; some 
days subsequently, the same animal and dose of pepsin being used, the course of the fever is 
to be modified by the antipyretic, and the heat-dissipation and heat-production of the two days 
contrasted. 



628 


GENERAL REMEDIES. 


tion and the dissipation of animal heat. In two experiments both func¬ 
tions were distinctly increased. When tetanic convulsions occur from 
antipyrin there is a marked rise of the bodily temperature. In both 
of the two calorimetric experiments in which the heat-production was 
increased, very large doses of antipyrin were employed, and it is believed 
that the animal suffered convulsions in the calorimeter. In almost all 
the experiments the decrease of heat-production was very much greater 
than the decrease of heat-dissipation: it would appear, therefore, that 
antipyrin in the normal dog primarily lessens heat-production, the 
fall of the heat-dissipation probably being the result, at least in part, 
of the lessened heat-production. In experiments upon dogs in which 
fever had been produced by injections of pepsin, both heat-production 
and heat-dissipation were markedly decreased, but usually heat-pro¬ 
duction was more affected than heat-dissipation, and there can be little 
doubt that the fall of temperature produced by antipyrin in fever is 
the result of a decreased heat-production. This is in accord with the 
chemical studies made by Umbach {Arch. f. Exper. Path. u. Pharm., 
xxi.) upon himself. He found that large doses of antipyrin, while not 
altering the amount of urine, caused a very pronounced decrease in the 
elimination of urea, and considers that he has proved that antipyrin 
produces a decrease in the tissue-changes of the respiratory and ali¬ 
mentary systems. Wiczkowski (quoted by Umbach), Walter, of St. 
Petersburg {Therap. Gaz ., vol. ii.), and F. Muller {Jahresb. fur Thier- 
chemie, xiv.) have also experimentally determined that antipyrin lessens 
the nitrogenous products of tissue-waste in fever. 

It should, however, be stated that in opposition to the results of 
Umbach, Wiczkowski, Muller, and Walter are those of Armand, who, 
in experiments upon himself, obtained a decided increase of the elimi¬ 
nation of urea as the result of the daily ingestion of forty-five grains 
of antipyrin. In experiments upon the normal rabbit Chittenden and 
Cummins ( Physiol. Labor. Shef. Sci. School, vol. ii.) were unable to find 
that antipyrin either in large or in toxic doses had any effect upon the 
elimination of carbonic acid. 

Therapeutic Action.— When antipyrin is given to a healthy man 
in a dose of half a drachm, it usually produces no marked symptoms, 
except some singing in the ears, slight nausea, and an uncertain fall of 
bodily temperature, which very rarely, if ever, amounts to more than 
one-tenth of a degree. After doses of a drachm or upwards, vomiting 
is very apt to occur, accompanied or preceded by giddiness and distress 
in the head. In fever cases, about half an hour to an hour after a dose, 
profuse sweating occurs, and it is at this time that the fall of tem¬ 
perature takes place. It does not appear, however, that the latter is 
produced by the diaphoresis. At least, according to Carl von Noorden 
{Berlin. Klin. Wochenschr., 1884, p. 523), the sweating can be arrested by 
the use of hypodermic injections of atropine or agaricin without affect¬ 
ing the fall of temperature. Moreover, the sweating is not invariably 


ANTIPYRETICS. 


629 


present, and in dogs, which do not sweat, antipyrin is a powerful 
antipyretic in fever. According to most authorities, the depression of 
temperature lasts longer than that caused by other antipyretics, con¬ 
tinuing from two to twenty hours. It is accompanied by a reduction 
of the rate but not of the force of the pulse. In some cases the sweat¬ 
ing is not profuse, and it is probably under such circumstances that 
observers have noticed a markedly increased diuresis. Usually the 
patient is more comfortable under the action of the drug than at other 
times; sometimes, however, there is distressing vomiting. 

Antipyrin may be employed as an antipyretic in almost any disease 
accompanied with high temperature, such as pneumonia , erysipelas , and 
typhus , scarlet , yellow , and typhoid fevers, rheumatism , etc.: it has also 
been freely given in the hectic fever of phthisis, but various observers 
state that in such cases it produces so much feebleness and general de¬ 
pression as to forbid its use. Nevertheless, my own observation is that 
when used with caution in phthisis it often gives great relief. In typhus 
fever it reduces the temperature, but in a number of recorded cases 
it has caused very serious collapse. It appears to have some spe¬ 
cific action in rheumatism, but does not in this respect equal salicylic 
acid. According to A. Pribram (Prayer Med. Wochenschr., 1884), in 
pneumonia the frequency of the respiration is distinctly lessened by it. 
In children it has been used with asserted good results by a number 
of clinicians, and it appears to be especially useful in the pneumonia 
and bronchitis of the young. 

Nearly a year ago statements were made that antipyrin is capable 
of relieving pain, and at the meeting of the French Academy of Medi¬ 
cine, April 18, 1887, M. See affirmed that antipyrin is a powerful anal¬ 
gesic, and that when given in doses of from forty-five to ninety grains 
a day it would control almost all forms of pain. Very recent articles 
by various clinicians, and my own experience, agree in confirming in 
great part the statements of the French professor, and there can be 
no doubt that antipyrin is a valuable agent for the relief of suffering. 
Especially is it effective in rheumatic pains and in migraine and other 
forms of neuralgia , in which the pain is the outcome of nerve-storm, 
and it will often control the pangs of locomotor ataxia; I have even 
seen it abort a gastric crisis. How it acts is entirely unknown, whether 
by a true analgesic influence or whether it simply puts aside the nerve- 
storm which is the cause of the pain. In violent hemicrania sleep fol¬ 
lows relief, and this has led Dr. J. E. Stubbert {Med. Rec., vol. ii., 1887) 
to conclude that antipyrin is a hypnotic,—a conclusion which is op¬ 
posed to my own experience. 

M. A. Chouppe states that antipyrin has great power in relieving 
uterine pains after parturition or in dysmenorrhcea, and that if it be 
given during labor along with ergot it allows the contractions to go on, 
but renders them painless. 

Antipyrin may be used in epilepsy with some hope of success, since 


630 


GENERAL REMEDIES. 


its influence in preventing the return of convulsions is sometimes 
extraordinary, although in the great majority of cases it fails entirely. 
I have studied it in a large number of cases, but am unable to point out 
any indications which will warrant in an individual case the a priori 
opinion that antipyrin will do good. The only method is that of trial. 
Not less than forty-five grains a day should be given, aud if, after a 
time, no cyanosis or muscular weakness mark the physiological action 
of the drug, and the convulsions still recur, the dose should be increased 
up to the physiological limit. 

The free use of antipyrin in disease is not unaccompanied with 
danger. Dr. Barrs {London Lancet , 1885, Feb. 28) reports a case in 
which thirty-five grains of antipyrin were administered at one time to 
a puerperal woman with a temperature of 103.6°, and followed in three 
hours by half the quantity, after which the temperature sank to 98°, 
and, in spite of stimulation, death occurred thirty-two hours later. 
There have been reported numerous cases in which cyanosis, disturbed 
respiration and circulation, and collapse have been produced by antipyrin 
given in doses of from thirty to forty-five grains; and Guttmann has 
recorded a case {Therap. Monatshefte, June, 1887) in which the admin¬ 
istration of fifteen grains caused facial cyanosis, increased frequency 
of respiration and pulse, dyspnoea, and sensations of extreme heat over 
the entire body; also a second ease in which along with these symptoms 
there was wide-spread oedema. Not rarely an eruption on the skin oc¬ 
curs, with more or less suffering and constitutional disturbance. In its 
most typical form this consists of small, reddish, irregularly circular 
spots, resembling somewhat those of measles, which are arranged in 
patches separated by sound skin. On pressure the red color usually 
disappears, leaving a brown pigmentation, which brown color also comes 
into view during the fading of the exanthem, and ordinarily continues 
five or six days. Sometimes the eruption takes the form of an intense 
erythema, with great swelling of the face, especially about the eyes, vio¬ 
lent burning sensations, and rise of temperature. (Case, Dr. S. Laache, 
Centralbl. f. Klin. Med ., 1886, 545.) 

Antipyrin may be administered hypodermically, by the mouth, or by 
the rectum. The hypodermic injections at times produce local irritation, 
but are usually well borne. The dose for a child of one or two years 
of age may be set down as three grains; for a child five years old, seven 
grains; for the adult the dose should not exceed twenty grains, repeated 
every one or two hours until from forty to sixty grains are given, or 
sweating comes on. In children it would not be safe to repeat the dose 
more than once. Some authorities prefer a single large dose of from 
forty to sixty grains in the adult. 

ANTIFEBRIN. 

This substance was discovered by Gerhard, and has been known in 
chemistry under the names of acetanilide and phenyl acetamide. It is an 


ANTIPYRETICS. 


031 


anilin in which one atom of hydrogen has been replaced by the radical 
acetyl; or it may be considered as an ammonia in which one atom of 
hydrogen is replaced by phenol and another atom by acetyl. It is a 
white crystalline substance, entirely without odor, having a bitter, 
mildly piquant taste. Whenever it gives a reddish-orange precipitate 
with hypobromite of sodium, it should be rejected as containing anilin. 
It is soluble in 160 parts of cold water, more soluble in warm water, 
very soluble in alcohol, ether, and chloroform. 

The medical virtues of antifebrin were fii-st discovered by Cahn and 
Ilepp, and have been abundantly confirmed by numerous observers. 
When given to healthy men in doses of seven to ten grains it usually 
produces no appreciable effect. The repetition of this commonly causes 
somnolence, constipation, occasionally headache or nausea, malaise, and 
a peculiar cyanotic condition of the face and extremities. When given 
to persons suffering from fever in doses of ten grains there is usually 
in about an hour fall of temperature, which reaches its maximum in 
two or three hours and may continue from six to seven hours. In 
some cases at this time the cyanosis is apparent; usually, but not 
always, the fall of temperature is accompanied by a profuse sweating, 
which is generally described by clinicians as being less than that pro¬ 
duced by corresponding doses of antipyrin. The fall of temperature 
is not dependent upon sweating, since it sometimes occurs without the 
sweating, and Dr. G. Pavai-Vajna ( Centralbl. Gesammte Therapie , 1887) 
finds that the sweating can be arrested in great part by atropine without 
interfering with the thermic action of the drug. In rare cases the 
lowering of the bodily temperature has been coincident with the occur¬ 
rence of collapse. Armin Hugher ( Corresp.-Blatt fur Schiceizer Aerzte, 
1887, xvii.) records a case in which there was an eruption evidently 
similar to that commonly produced by antipyrin. The spots were small, 
but especially abundant upon the face and forehead, and of a dark-red 
color. Mydriasis and deafness, with ringing in the ears, have been 
noted occasionally by other observers. Collapse appears to be less fre¬ 
quent than with antipyrin. The experiments of Dr. Hobart A. Ilare 
( Therap. Gaz., 1887) show that at present inexplicable cardiac failure 
may occur suddenly. 

In the experiments of Herczel (Wien. Med. Wochenschr ., 730, 1887), 
the symptoms produced by fifteen to twenty grains in rabbits were 
loss of the reflexes, tremors deepening into periodic convulsive move¬ 
ments, great fall of temperature, frequent, irregular, superficial respi¬ 
ration, retention of urine, coma, and general paralysis, ending, if the 
dose had been large enough, in death, which could not bo prevented 
by artificial respiration. The heart was arrested in diastole. After the 
prolonged action of the drug there was fatty degeneration of the heart, 
liver, and kidneys. Weill noticed (Bull. Therap ., cxii. 150; also Thesis, 
Paris, 1887), in addition to these symptoms, an aniesthesia, which in 
the later stages of the poisoning was almost complete. 


632 


GENERAL REMEDIES. 


Notwithstanding the number of papers written concerning anti¬ 
febrin, our knowledge of its physiological action is very incomplete. 
The cause of the convulsions does not seem to have been determined. 
The coma which is present in the advanced stages of the poisoning 
indicates that, directly or indirectly, antifebrin affects the cerebral func¬ 
tion, but consciousness is stated by experimenters to be preserved at a 
time when the lower portion of the nervous apparatus is distinctly 
affected. According to the experiments of Professor Bokai ( Deutsch. 
Med. Wochen., Oct. 1887), antifebrin paralyzes motor-nerve endings of 
the frog’s muscles in a manner similar to curare, and when brought in 
contact with the muscle itself for a sufficient length of time destroys 
its capability of contraction. In the poisoned animal just before death 
the muscles respond, however, actively, although irritation of motor- 
nerve trunks fails to elicit response. Usually when antifebrin is given 
to patients with fever there is a fall in the pulse-rate corresponding 
to the fall of temperature. The size of the pulse is also reduced, and 
it may even become thready. Weill has found that, injected into the 
frog, the drug causes at first an acceleration of the heart’s beat, with 
apparent increase in the force of the impulses, followed after a time by 
slowing and irregularity of contraction. In the earlier stage the size 
of the pulse-wave is increased and the respiratory curve is more ac¬ 
centuated ; later the pulse-oscillations diminish, and become irregular 
and quickened, and if the dose has been large enough the manometric 
writing resembles that produced by asphyxia. In the earlier stages 
of the action there is a slight rise in arterial pressure. 

The most characteristic symptom produced by large doses of anti¬ 
febrin is the peculiar discoloration of the blood, which appears to be 
due to the formation of methtemoglobin. Dr. Herczel states that the 
red corpuscles do not adhere in rouleaux, that they are somewhat gran¬ 
ular, and that, when the drug is given to dogs for a length of time, 
the blood is less alkalescent than normal, and contains in its serum 
dissolved coloring-matter. According to Lepine and Aubert ( Gaz. 
Med. de Strasb., i., 1887; also Herczel), the oxygen of the blood is 
distinctly decreased. 

According to Dr. Pavai-Vajna, antifebrin is eliminated in the same 
manner as anilin,—namely, as paramidophenol sulphate. Matusorszky 
is stated to have obtained the reaction of this substance in the urine 
not only when antifebrin had produced cyanosis, but in every case in 
which it had been given at all. This method of elimination indicates 
that the antifebrin breaks up in the organism into acetic acid and 
anilin, and that the anilin is then oxidized into paramidophenol, which 
unites with sulphuric acid.* Cahn and Hepp, however ( Le Progres 


* The changes which occur in antifebrin in the system have led to the theory that its 
medical virtues are dependent upon the liberation of anilin in the blood. The symptoms 
produced by antifebrin are certainly similar to those caused by anilin. Thus, Dr. Herczel 
states that in a case of anilin-poisoning the symptoms were colossal cyanosis, sweating, vom- 



ANTIPYRETICS. 


G33 


Med., Jan. 1887) affirm that antifebrin escapes finally with the urine in 
great part unaltered, and that only a small portion of it is converted 
into anilin and acetic acid; but Muller, on the other hand, states that 
antifebrin cannot be found at all in the urine, and consequently that it 
undergoes entire decomposition. It is probable that the proportion of 
antifebrin which is decomposed varies with the size of the dose and 
the condition of the system. 

Temperature .—Attempts to decide the method in which antifebrin 
influences the bodily temperature have been made by Dr. II. A. Hare 
and E. M. Evans ( Therap. Gaz., 1887). In fifteen experiments upon 
normal animals, which in nearly all cases were allowed to run free, Dr. 
Hare obtained a distinct fall of temperature from antifebrin,—a result 
confirmed by Dr. Evans, but not in accord with the results of Cahn 
and Hepp, who found that antifebrin had not a constant influence 
upon the temperature of the normal animal. Dr. Hare, employing the 
calorimeter used by myself, found that in the normal animal heat-dis¬ 
sipation and heat-production were variously affected, in some cases 
being notably increased, in other cases notably decreased, and in others 
not distinctly altered. Dr. Evans, employing the D’Arsonval calorim¬ 
eter, also reached various results. In eleven experiments heat-dissi¬ 
pation was decreased nine times, while heat-production was increased 
four times and decreased five times. In examining the records of the 
calorimetric experiments made by Drs. Hare and Evans on the normal 
animal, I find that not only did the rectal temperature not fall under 
the influence of antifebrin, but in nearly every instance there was a 
very distinct rise, amounting in some cases to over a degree. It is evi¬ 
dent, therefore, that these experiments cannot be used to explain how 
antifebrin reduces temperature when it does cause a fall. The attempt 
to reason how a certain result is produced by a remedy from experi¬ 
ments in which that result was not produced is necessarily futile. 

In Dr. Hare’s experiments made upon dogs in which fever was 
caused by the injection of pepsin, antifebrin failed to produce any con¬ 
stant fall of the bodily temperature, probably because the dose was 
not large enough. In the calorimetric studies heat-production was 
usually decreased, but sometimes it was increased,—an assertion which 
is also true of heat-dissipation. These experiments must likewise be laid 
aside, because there was no fall of temperature caused by the anti¬ 
febrin. In Dr. Evans’s experiments with fever produced by the injec¬ 
tion of albumose, the antifebrin nearly always caused a distinct reduc¬ 
tion of-temperature. In the calorimetric studies the results obtained 
were constant, there being in each of the six consecutive experiments 
a decrease in both the hourly heat-dissipation and the hourly heat-pro- 


iting, tinnitus nurium, dyspnoea, fixedness of pupils, disturbance of sensibility, and a tem¬ 
perature-fall of 5.3° C., accompanied by a marked decrease in the coloring-matter of the blood 
and of the number of red blood-corpuscles. 



634 


GENERAL REMEDIES. 


duction, the amount of decrease seemingly bearing some relation to 
the fall of temperature. It is plain that a decrease of heat-dissipation 
would have a natural tendency to elevate bodily temperature, and 
therefore the fall of temperature must have been due to the decrease 
of heat-production, which in turn gave rise to the decrease in the heat- 
dissipation. The experiments of Dr. Evans, therefore, so far as they 
go, indicate that in fevered animals antifebrin produces a fall of the tem¬ 
perature by decreasing heat-production. 

Therapeutics. —The medical apjdication of antifebrin appears to 
be exactly parallel to that of antipyrin. There is some reason for be¬ 
lieving that it is less apt than is antipyrin to produce collapse, or pain¬ 
ful eruptions upon the surface, or other disagreeable effects. This may, 
however, simply be because it has been less freely used than antipyrin, 
since it is certainly capable of having any of these actions. It may be 
substituted for antipyrin for the reduction of temperature in fever, for 
the relief of pain, and for the prevention of epileptiform attacks. 

According to Lepine {Lyon Med., vol. xlvi., 1886), it will relieve not 
only the fulgurant pains of spinal disease, but also the tremors produced 
by multiple sclerosis. 

Thallin, or Parachinanisols, occurs in the forms of thallin sulphate 
and thallin tartrate,—each a yellowish-white crystalline powder, with 
an odor somewhat resembling that of the coumarin bean, and a saline, 
bitterish, aromatic taste. The sulphate is soluble in seven parts of cold 
water, the tartrate in ten parts of cold water. Physiologically and 
therapeutically the preparations are equivalent. Thallin is certainly 
a powerful antipyretic. According to the researches of N. Tschisto- 
witsch ( Centralbl . /. Med. Wissensch., 1885, xxiii. 930), in the normal 
warm-blooded animal after the ingestion of thallin the bodily tempera¬ 
ture sometimes, but not always, falls, while in the fevered animal the 
fall of temperature is almost invariably pronounced, the antipyretic 
influence lasting two to six hours, and not being accompanied with any 
marked depression of blood-pressure unless the dose has been unneces¬ 
sarily large, when the pulse becomes slower and the pressure sinks. 
The fall of pressure is said to be partly the result of a vaso-motor 
paralysis, partly the result of cardiac depression. 

To man thallin has been given in doses of from four to eight grains 
for the relief of fever. It produces usually in half an hour to an hour 
a fall of temperature, accompanied with excessive sweating, and not 
rarely with an erythematous or cyanotic discoloration of the skin of 
the face and extremities. In many cases there have been violent chills, 
lasting from a few moments to several hours, usually preceding the rise 
of temperature after the fall. Vomiting is sometimes produced, and 
very commonly there is diarrhoea, which may be severe. Several ob¬ 
servers have also noticed albuminuria (see Wien. Med. Wochenschrift, 
1887). According to the experiments of Peter J. Martin ( Therap . Gaz. } 


ANTIPYRETICS. 


635 


May, 1887), the fall of temperature is chiefly clue to increased dissipa¬ 
tion of heat, although in some of his cases heat production was also 
decreased. Professor E. Kreis has discovered that a solution of four to 
four and a half per cent, of sulphate of thallin is capable of destroying 
microbes, and Professor Goll, acting upon these suggestions, found 
that injections of two- to two-and-a-half-per-cent. solutions of thallin 
repeated three or four times a day, and aided by the internal adminis¬ 
tration of the drug in doses of three grains every three hours, have 
remarkable power in arresting gonorrhoea. In gleet the irrigation of 
the urethra with a one- to one-and-a-half-per-cent. solution of thallin 
produced excellent results. 

Kairine is a grayish-yellow crystalline powder, of a bitter taste, 
easily soluble in water and in alcohol. When taken internally in doses 
of from five to ten grains repeated every three or four hours, it pro¬ 
duces in a short time a copious diaphoresis, accompanied with excessive 
dilatation of the cutaneous vessels and a reduction in frequency of the 
pulse and respiration. It is said to cause dangerous cardiac depression 
by a direct influence on the cardiac muscle, and to have also a very 
decided influence upon the red blood-corpuscles, producing a peculiar 
lividity and general cyanosis, with threatening collapse. The reports 
in regard to it have been so unfavorable that it has not been used to 
any considerable extent in practical medicine. It has no advantages 
over antipyrin and antifebrin, and appears to be more dangerous. 

Acetphenetidin.— This substance, which is an acetyl derivative of 
amidophenol, crystallizes in tasteless, colorless needles, slightly soluble 
in water, more so in alcohol. It has been experimented upon by O. 
Hinsberg and A. Kast (Centralbl. f. Gesammt. Therap., April, 1887), who 
find that when given to dogs in doses of 0.15 to 0.2 gramme per kilo it 
has no effect, but in very large doses produces vomiting, irregular gait, 
hurried respiration, and somnolence, followed by general cyanosis and 
discoloration of the blood, due to the formation in it of methremoglobin. 
The same authors found that when given to phthisical cases in doses of 
three to seven grains it caused a pronounced fall of temperature, with 
redness of the skin, but little sweating, and no marked alteration of the 
pulse, unless it were increased tension. In no case was there any gas¬ 
tric disturbance or collapse. These statements have been to some extent 
confirmed by Dr. T. J. Mays (Med. News, August 20, 1887). 


CLASS II—LOCAL REMEDIES. 


FAMILY L—STOMACHICS. 


There are various substances which have the power of so affecting 
the gastro-intestinal mucous membrane as to increase the functional 
activity of the various glands and thereby aid digestion. Certain of 
these substances are of vegetable origin and of a bitter taste, and, while 
affecting markedly the gastro-mucous membrane as stimulants, have 
little or no influence upon the general system. These are the so-called 
simple bitters , which in previous editions of this book have been con¬ 
sidered under the general heading of tonics. Although simple bitters 
may, by increasing the amount of food taken, affect the general nutri¬ 
tion of the body, it is evident that they are distinct in their action 
from substances like iron, which more or less directly influence the 
general tissues of the organism. They are essentially locally-acting 
drugs. Probably all bitter vegetable substances are stimulants to the 
gastro-mucous membrane, but in many of them, as in morphine and 
strychnine, such power is completely overshadowed by other inherent 
properties. Some of these active bitter vegetable substances are in¬ 
deed employed on account of their influence upon the alimentary tract, 
notably quinine and strychnine, but in others of them, like morphine, 
the local is entirely swallowed up in the general influence. By virtue 
of their stimulant power the simple bitters produce, when in overdoses, 
nausea, and may even cause active irritation of the gastro-mucous 
membrane. They have also some tendency to act upon the bowels. 
They are essentially irritant, and are contra-indicated by inflammation 
or over-sensitiveness of the alimentary mucous membrane. They are 
especially indicated by loss of appetite, when such loss of appetite is 
the outcome of a depressed condition of the stomach, but when it is 
the result of gastro-inflammation they will do harm. A second class 
of stomachics are the so-called aromatics , which depend for their ac¬ 
tivity upon the presence of a volatile oil. They differ from the simple 
bitters in being more powerful but less permanent as local stimulants. 
(See page 641.) A third class of drugs contain both volatile oil and 
bitter principle, and unite the properties of the aromatics with those 
of the simple bitters. These are the so-called aromatic bitters. 

63 6 




STOMACHICS. 


637 


SIMPLE BITTERS. 

QUASSIA. U.S. 

The wood of Simaruba excelsa, a large tree, native of Jamaica. This 
wood is light both in density and color, somewhat resembling that of 
the tulip-tree, but distinguished by its intensely bitter taste. It is kept 
in the shops in billets and in raspings. The active principle of it ap¬ 
pears to be Quassin, an intensely bitter, neutral, crystalline principle 
discovei’ed by Winckler ( Repert.f. Pharmacie, Bd. liv. p. 85, Bd. lv. p. 85). 
Simaruba , the bark of the root of Simaruba officinalis, also contains 
quassin, and may be substituted for quassia. 

Physiological Action. —Quassin is said in large doses to be actively 
poisonous to insects, and even to mammals (Stille’s Therapeutics , i. 472 ; 
Husemann, Die Pflanzenstoffe, p. 718) ; but I have met with no detailed 
study of its action except that of I. Hoppe, who experimented upon 
frogs ( Deutsche Klinik, xi., 1859). In doses of one grain it usually 
produced death in a short time. The symptoms were great weakness, 
with, in most cases, convulsions and sometimes convulsive tremblings, 
failure of respiration, and finally cessation of cardiac action. The 
functional activity of the nerve-trunks was much impaired, that of the 
muscles to a less extent. Locally, quassin appeared to act as an irritant 
as well as a powerful poison to both nervous and muscular tissues. Dr. 
Campardon found that in doses of five milligrammes of the pure crys¬ 
talline form, or five centigrammes of the commercial amorphous variety, 
quassin acts upon man as a powerful bitter tonic, notably increasing 
the secretion of bile and of the urine, and causing some looseness of 
the bowels and stimulation of the bladder. Fifteen milligrammes of 
the crystalline quassin caused violent frontal headache, burning pains 
in the oesophagus and throat, nausea, vomiting, vertigo, excessive ner¬ 
vous restlessness, diarrhoea, and vei*y frequent micturition, but dimin¬ 
ished renal secretion (Bull. Therap., ciii. 410). 

Therapeutics. —Quassia is probably the most active of all the simple 
bitters, and may be used whenever such remedies are indicated. In 
cases of seat-worms in children, a strong infusion of quassia (gii to Oj) 
affords a most harmless and efficient injection. Its exhibition should 
be preceded by an enema of simple water, after a stool, so as thoroughly 
to wash out the rectum and allow access to every fold of the rectal 
mucous membrane. The officinal preparations are a tincture ( Tinctura 
Quassice —1 to 9, U.S.), dose, twenty drops to a teaspoonful; a very ex¬ 
cellent watery extract (Extractum Quassice , U.S.), which may be given 
in pills containing from one to three grains; and a fluid extract ( Ex¬ 
tractum Quassice Fluidum ), dose, five to ten drops. 

GENTIAN A-GENTIAN. U.S. 

The root of Gentiana lutea, or the yellow gentian of the Alps. This 
root occurs in the shops either in pieces of various sizes and shapes but 


638 


LOCAL REMEDIES. 


generally several inches in length, or else in transverse slices. The 
texture is spongy, the odor faint but peculiar, and the taste bitter. It 
contains gentisic acid, which was discovered by Leconte and is tasteless 
and physiologically inert. The active principle is probably the gentio- 
pikrin of Kromayer, a neutral, crystalline substance, of an intensely 
bitter taste. 

Therapeutics. —Gentian is one of the most efficient of the simple 
bitters, and may be used whenever such a remedy is indicated. It is 
never given in substance, but in one of its preparations. These are the 
compound tincture (Tinctura Gentiance Composita, U.S.), which contains 
gentian (1 to 12.5), bitter orange peel, and cardamom—dose, one fluid- 
drachm to half a fluidounce; the watery extract ( Extractum Gentiance , 
U.S.), dose, two to four grains, and the fluid extract (Extractum Gentiance 
Fluidum , U.S.), dose, ten minims to half a fluidrachm. The compound 
infusion , formerly officinal, was a valuable preparation, containing some 
alcohol, and much used in doses of one to two fluidounces. 

NECTANDRA. 

Bebeeru Bark is the bark of Nectandra Rodisei, a large tree which 
grows in Guiana and the neighboring parts of South America and is used 
in ship-building under the name of “ green-heart.” It occurs in large 
flat pieces, and contains an alkaloid which was discovered by Dr. Mac- 
lagan, of Edinburgh. According to the researches of Walz (AT. Jahrb. 
Pliarm., 1861, xii. 302) and of Fliickiger ( Ibid ., 1869), this alkaloid is 
identical not only with Buxine, obtained by Faune in 1830 from Buxus 
sempervirens, but also with Pelosine, discovered by Wiggers in Pareira 
brava. Bebeerine , or, as it should be called, buxine, is whitish, amor¬ 
phous, inodorous, very bitter, very slightly soluble in water, freely so in 
ether and alcohol, and forms uncrystallizable salts. Dr. Maclagan 
found a second alkaloid, Sipeerine, in bebeeru bark, but it is probably 
only altered bebeerine. 

Physiological Action. —Our knowledge of the influence of bebeerine 
upon the system is exceedingly incomplete. Albers ( Virchow's Archiv, 
Bd. xxiv.) found that three grains introduced beneath the skin of a 
large frog produced death in six and a half hours. There was first a 
period of quiet with accelerated breathing, then tonic and clonic general 
convulsions, seemingly associated with muscular weakness, but with no 
increase of the reflex activity. Professor Binz ( Virchow's Archiv, Bd. 
xlvi. p. 130) has determined that bebeerine exerts some destructive influ¬ 
ence over infusorial forms of life, but that it is in this respect not nearly 
so powerful as the cinchona alkaloids. 

Therapeutics. —Bebeerine was originally proposed by Dr. Maclagan 
as a substitute for quinine in malarial diseases, and has been quite exten¬ 
sively tried. It appears to possess some antiperiodic powers; but they 
very probably are not superior to those of the more powerful simple 
b’tters, and are certainly very inferior to those of quinia, so that bebeerine 


STOMACHICS. 


639 


is at present very seldom if ever used. The unofficinal sulphate may 
be given in acidulated solution in doses of from two to five grains. 

HYDRASTIS. U.S. 

The rhizome of Hydrastis Canadensis, an indigenous perennial, com¬ 
monly known as Golden Seal. It contains the alkaloids hydrastine, ber- 
berine , and probably a third alkaloid, xanthopuccine. 

Physiological Action. —According to Falck and Guenste, toxic doses 
of berberine cause in dogs restlessness, convulsive tremblings, thirst, and 
diarrhoea, and finally partial paralysis of the hind legs. From seven to 
fifteen grains of it killed rabbits in from eight to forty hours. The symp¬ 
toms were increased frequency of respiration and tremblings, followed 
by decrease of the rate of breathing, paresis, paralysis of the hind legs, 
great dyspnoea, and finally convulsions. Both Dr. Schurinow and Curci 
(see Land. Med. Bee., Oct. 11, 1886) agree that berberine causes the 
arterial pressure to fall rapidly from vaso-motor paralysis,—Schurinow 
affirming, however, that late in the poisoning the peripheral vagus is 
paralyzed, Curci that that nerve is not affected at all. The heart is at 
first slowed, and afterwards rendered more rapid, the muscular fibres, 
according to Curci, being finally paralyzed. The respii*atory centres 
are depressed. Abdominal peristalsis is greatly increased. The urine, 
after toxic doses, becomes albuminous, and sometimes contains epithe¬ 
lial casts, while after death the kidneys are found inflamed. (Curci.) 
The action of the drug on the nervous sj'stem is feeble, but there is 
finally loss of voluntary power and of reflex activity, and also of sen¬ 
sation, the anaesthesia being according to Curci of central origin, but 
according to Schurinow the result of paralysis of the sensory nerve- 
trunks. In man, as yet, no violent symptoms have been recorded as 
produced by berberine. Buchner took nearly twenty grains without 
causing anything more serious than a loose stool. As a bitter tonic 
it has been used by various physicians in doses of from two to five 
grains, and its action in this dose appears to be that of a simple bitter. 
It may be given in pill form or dissolved in alcohol. 

The dominant alkaloid of hydrastis is hydrastine. In toxic doses 
it produces spinal tetanic convulsions, increased reflex activity, and 
death from cramp-asphyxia. (Bartholow, Lloyd's Drugs and, Medicines 
of North America; Mays, Therap. Gaz ., 1880.) After death the excita¬ 
bility of the motor nerves is below normal, probably from exhaustion, 
as the drug appears to have very little direct action on the nerve-fibre. 
Dr. Mays found that given internally to frogs it causes anaesthesia, 
which is not prevented in a leg by tying the artery, although the alka¬ 
loid when brought in contact with a nerve-trunk paralyzes it: so that 
it probably acts upon both the sensory cord and the sensory nerves. 

The action of hydrastine upon the circulation has been especially 
investigated by Fellner {Wien. Med. Jahrbucher, 1885). He finds that 
in warm-blooded animals moderate doses injected directly into the vein 


640 


LOCAL REMEDIES. 


produce a momentary fall of pressure followed by a distinct rise which 
continues for a length of time. After larger doses this rise is followed 
by a fall of pressure, or the primary fall of pressure continues up to 
death. During the earlier portion of the stage of increase of the 
arterial pressure the pulse is slow ; later it becomes rapid, which rapidity 
persists after the fall of pressure. To determine the cause of the rise 
of the arterial pressure, Dr. Fellner made experiments after section 
of the splanchnic nerve, and after section of the medulla oblongata. 
Neither of these operations prevented the rise of the arterial pressure. 
It appears to be a natural conclusion that the rise of pressure is not of 
vaso-motor origin, but is the result of a stimulant influence upon the 
heart. This conclusion is, however, denied by Fellner, because the 
rise occurs when the pulse is veiy slow, and he believes that it is due 
to a peripheral contraction produced by a direct action of the drug 
upon the capillary walls. Further studies seem to me essential before 
we can come to any conclusion in regard to the exact action of hydras- 
tine upon the vaso-motor system. Dr. Slavatinski ( Lancet , May, 1886) 
states that finally in poisoning with the drug the vaso-motor centre is 
paralyzed. Professor Boberts Bartholow has shown that the alkaloid 
when placed upon the exposed heart of the frog causes diastolic arrest 
with loss of electro-excitability; and it is probable, therefore, that the 
final fall of pressure is due to a paralyzing influence exerted on both 
the heart and the vaso-motor system. 

Both Fellner and Slavatinski affirm that hydrastine has a distinct 
ecbolic action, causing uterine contractions in the non-pregnant uterus, 
and abortion in pregnant rabbits. Dr. Slavatinski reports a case of 
premature labor produced by hypodermic injections of two to three 
grammes repeated daily. Dr. Mays has found that when hypodermi¬ 
cally injected in doses of one-eighth of a grain it produces a distinct 
lowering in the frequency of the pulse, with some apparent increase 
in the force of the circulation. 

Therapeutics. —Under the name of hydrastin there is sold com¬ 
mercially a substance consisting of berberine, hydrastine, and probably 
some resin. Employing this resinoid mixture. Professor Butherford 
(Brit. Med. Journ., 1879, vols. i., ii.) found in his experiments upon the 
lower animals a marked increase in the biliary secretion. When locally 
applied, the preparations of hydrastis have a very remarkable effect 
upon the mucous membranes. They have been used with asserted ex¬ 
cellent results in chronic gastro-intestinal catarrhs , especially those due 
to alcoholic excesses. Dr. Mays believes that the drug is useful in these 
cases not only by its action on the alimentary tract, but also by its 
stimulant influence upon the circulation. In the second stages of gonor¬ 
rhoea , after the acute inflammation has been subdued, hydrastin, or 
the fluid extract, suspended in mucilage, is of very great service. Five 
grains of the commercial impure hydrastin, or ten to twenty minims 
of the fluid extract, may be used to the ounce of injection. It is prob- 


STOMACHICS. 


641 


able that in otorrhoea, nasal, vaginal, and other mucous catarrhs equally 
good results might be obtained. Hydrastin has also been employed as 
an antiperiodic, and probably has the action of a simple bitter upon 
the stomach. 

The proper internal dose of pure hydrastine cannot be considered 
as settled; the commercial hydrastin varies in its constitution, and may 
often be given in doses of five to ten grains. The dose of the pure 
alkaloid is given by Dr. Mays as one-fourth of a grain. 

CALUMBA-COLUMBO. U.S. 

The root of Cocculus palmatus, a climbing vine of Mozambique. It 
occurs in the shops in transverse disk-like slices, oval or circular in out¬ 
line, one or two inches in diameter, of a spongy texture, having a yellow¬ 
ish surface, a very bitter taste, and a slightly aromatic odor. It contains 
a great deal of starch, besides berberine, and, it is said, in lesser amount, 
Columbin, a bitter neutral principle crystallizing in rhomboid prisms 
or needles. Dr. F. Roux ( Comptes-Rendus Soc. Biolog., 1884, i. 33) has 
found that columbin given to pigeons in doses of ten centigrammes 
produces death, preceded by failure of the appetite, marked signs of 
gastro-intestinal irritation, and jaundice. 

Therapeutics.— A bitter, slightly aromatic tonic, useful as a sto¬ 
machic in cases in which a simple bitter is indicated. It is not used in 
substance. Its preparations are—a tincture ( Tinctura Calumbce —1 to 9, 
U.S.), dose, one to two fluidrachms; and a fluid extract (Extraction 
Calumbce Fluidum, U.S.), dose, fifteen minims to half a fluidrachm. 

EUPATORIUM—THOROUGHWORT. U.S. 

The herbal parts, gathered after flowering, of the indigenous Eupato- 
rium perfoliatum, a tall, coarse composite, recognizable by its perfoliate 
leaves, through whose centre grow the stems and branches. This drug 
given in cold infusion (3i to Oj—dose, fji-ii) is an efficient but dis¬ 
agreeable bitter tonic. Its chief employment is as a sudorific. The 
hot infusion when taken freely (five to six ounces), the patient being 
well covered in bed, produces free sweating, and has been very largely 
used in “general colds,” muscular rheumatism, etc., for this purpose. 
The only objection to the remedy is its disagreeable taste. In the dose 
of a pint the infusion has been employed as an emetic. The fluid ex¬ 
tract (Extractum Eupatorii Fluidum, U.S.) may be used in doses of a 
fluidrachm to a fluidounce. 

Chirata, U.S., the herb and root of a plant growing in the north¬ 
ern part of India, is one of the best of the simple bitters, and is 
believed by some to exert a peculiar influence over the liver. When¬ 
ever a simple bitter is indicated, this drug may be employed, especially 
if a cholagogue action be desired. The solid extract is an excellent 
preparation in doses of one to two grains; the fluid extract (Extractum 

41 


642 


LOCAL REMEDIES. 


Chiratce Fluidum, U.S.) may be given in doses of five to ten minims; 
and the tincture ( Tinctura Chiratce —1 to 9, U.S.) in doses of a fluidrachm. 

PRUNUS VIRGINIANA—WILD CHERRY BARK. U.S. 

Wild cherry bark is the product of Prunus (Cerasus) serotina or 
wild cherry tree, not of Prunus Yirginiana or choke-cherry, whose 
name it bears. It occurs in pieces of various sizes, usually without epi¬ 
dermis. The color is a reddish cinnamon ; the taste slightly astringent, 
bitter, and peculiar, resembling that of peach-leaves. It contains tannic 
acid, bitter extractive, amygdalin, and emulsin. Amygdalin is a nitro¬ 
genous, crystallizable, odorless glucoside, of a slightly bitter taste. It 
is soluble in water and alcohol, but not in ether. Emulsin is an albu¬ 
minous principle, which is soluble in water, and, like other forms of 
albumen, is coagulated by heat, alcohol, acids, etc. When amygdalin 
in watery solution is brought in contact with emulsin, it is decomposed, 
forming prussic and formic acids and a colorless, thin, volatile oil, which, 
when pure, has a peculiar agreeable odor and a burning taste. Accord¬ 
ing to Liebig and Wohler {Ann. Chem. Pharm., xxii. 1), seventeen grains 
of amygdalin yield one of hydrocyanic acid: therefore, if thirty-four 
grains of amygdalin be mixed with sixty-six grains of an emulsion of 
sweet almonds, a two-per-cent, (by weight) solution of hydrocyanic 
acid will be formed. 

Physiological Action. —Amygdalin administered by itself is nearly, 
if not quite, without effect upon the organism. Widtmann and Denk 
(Husemann, Die Pflanzenstojfe , p. 688) took as much as sixty grains of 
it without inducing any effect, and their results have been confirmed by 
Reil and others. Lehmann, it is true ( Ibid .), found that at times fifteen 
grains of it by the mouth were sufficient to cause death in the rabbit; 
but Kolliker and Muller have shown that this was owing to its being 
converted into prussic acid by the emulsin contained in the green 
herbage in the stomach of the rabbit. 

Therapeutics. —In wild cherry bark properly administered there 
are three active ingredients,—tannic acid, bitter extractive, and prussic 
acid ; and to their combined action the general effect is due. As the 
tannic acid is in small quantity, its influence is not marked; but proba¬ 
bly some of the reputation which the remedy formerly enjoyed as being 
useful in the night-sweats of phthisis was due to it. The amount of 
prussic acid in Prunus Yirginiana is too small to have any perceptible 
effect, and I have never been able to detect any influence produced by 
wild cherry bark other than that of a feeble astringent and tonic. It 
has been very largely used in phthisis, and has been supposed not only 
to act as a tonic and astringent, but also to exert a calmative influence 
on the nervous system. 

The infusion {Infusum Pruni Virginiance —1 to 25, U.S.) is useful as 
an adjuvant to other tonics, especially sulphuric acid, in debility with a 
tendency to night-sweats during convalescence from acute disease. The 


STOMACHICS. 


643 


dose is one to two wineglassfuls. On account of its pleasant taste and 
its traditional reputation, the syrup (Syrupus Pruni Virginiance , U.S.) is 
often employed as the basis of cough-mixtures. The fluid extract ( Ex - 
tractum Pruni Virginiance Fluidum, U.S.) may be given in doses of from 
half a fluidrachm to a drachm. 


AROMATICS. 

The aromatie oils are essentially local irritants, causing when taken 
into the mouth intense burning pain, and, when confined upon the skin, 
rubefaction, blistering, and finally, if the contact be very prolonged, 
more destructive changes. Internally, taken in very large doses, they 
cause burning pain in the stomach, increased activity of the circulation, 
and a species of intoxication. In sufficiently large quantities they are 
irritant narcotic poisons. When administered in therapeutic doses they 
act almost exclusively upon the alimentary canal. As compared with 
that of the simple bitters, their influence is more powerful and more 
transient. They do not permanently increase the digestive power, but 
simply increase action for the time being. They are employed chiefly 
—to give pungency to bitter tonics; as carminatives , to stimulate the 
intestines to contract upon and expel flatus; to prevent the griping of 
purgatives; to disguise the taste of medicines, and to render nauseating 
drugs acceptable to the stomach; and to act as condiments and aid in 
the digestion of the food. 

Injected into the circulation, most volatile oils lower the blood-press¬ 
ure by depressing the heart’s action, and even in comparatively small 
doses may cause immediate diastolic arrest. In this respect oil of cloves 
is one of the most powerful. Their cardiac action is undoubtedly direct 
and upon the heart itself: other muscular structures would seem to be 
similarly affected, as H. Kobert has found that the oil of mace directly 
lowers muscular excitability (Arch. f. Exper. Path. u. Pharm ., xv. 22). 

Some of the tonic drugs containing a volatile oil also have in them 
a bitter principle which modifies th#ir action. Such drugs may be 
known as aromatic bitters ; as bitters they are less powerful than such 
drugs as quassia, and are especially indicated where the stomach is 
delicate and easily nauseated. 

Inflammation of the stomach or bowels is the chief contra-indication 
to the use of aromatics. Unlike the simple bitters, they are often very 
useful in diarrhoea of nervous irritability or of relaxation, when no 
decided inflammation exists. 

There is one property which is probably common to the aromatic 
oils, and which may therefore be mentioned here with propriety,— 
viz., the power of producing local anaesthesia. In China the oil of 
peppermint has long been used locally in neuralgia; and my own ex¬ 
perience with our native oil is in accord with that of Dr. A. Wright 
(Lond. Lancet , 1874, ii.; see, also, Gaz. Med., 1874) in finding it efficient 


644 


LOCAL REMEDIES. 


in neuralgia and subacute rheumatism. A rag soaked with it should 
be laid upon the part, and, when the burning is no longer endurable, 
cosmoline applied. The power of oil of cloves in benumbing sensitive 
dentine or exposed nerve-pulp is well known. (See Menthol, p. 607.) 

Cinnamomum. U.S. — Cinnamon is the bark of Cinnamomum zey- 
lanicum, a native of Ceylon, and of C. aromaticum, growing in China. 
The finest variety of cinnamon, that from Ceylon, occurs in long, 
closely-packed quills of a thin, very aromatic bark. Cassia bark , or 
Chinese cinnamon , is coarser, more broken, and less aromatic. Both 
varieties contain tannic acid and a yellowish volatile oil ( Oleum Cinna- 
momi , U.S.), which on account of its great fragrance and very pleasant 
taste is largely used, in doses of from one to three drops, as an adju¬ 
vant, or to disguise the flavor of less agreeable drugs. Cinnamon water 
(Aqua Cinnamomi —f3ss to Oij, U.S.) is used solely as a vehicle. The 
spirit of cinnamon (Spiritus Cinnamomi —oil 1 to 10, U.S.) is adminis¬ 
tered in doses of half a fluidrachm; the tincture (Tinctura Cinnamomi 
—1 to 10, U.S.) in doses of one to two fluidrachms. Pulvis Aromaticus. 
U.S.— Aromatic Powder (cinnamon, ginger, cardamom, nutmegs). An 
elegant carminative powder; dose, ten to twenty grains. 

Caryophyllus. U.S. — Cloves are the unexpanded flowers of Caryo- 
phyllus aromaticus, a tree growing in the Molucca Islands. This aro¬ 
matic, largely used as a spice, contains an exceedingly pungent volatile 
oil, officinal as Oleum Caryophylli. This is a yellowish oil, becoming- 
dark by age, which, besides being used as a carminative and an 
aromatic, is often employed to benumb sensitive dentine, or even 
exposed pulp, in caries of the teeth. Dropped on a piece of cotton and 
placed in the cavity, it will frequently cure toothache. Dose, one to 
two drops. The mfusion, or clove tea (Infusum Caryophylli —5ii to Oj), 
is made with boiling water; the dose is a wineglassful. 

Myristica. U.S. — Nutmeg is the kernel of the fruit of Myristica 
moschata, a tree inhabiting the Molucca Islands. The nutmeg contains 
both a fixed and a volatile oil. Mace ( Macis , U.S.P.) is the arillus or 
outer imperfect supernumerary coating of the seed. It contains a vola¬ 
tile oil identical with that of the nutmeg. The nutmeg is possessed 
of narcotic power, and it is said that one or two when taken will pro¬ 
duce a dreamy, half-unconscious condition. In a boy aged about eight 
years fatally poisoned by an unknown quantity of nutmeg, there was 
complete coma, with suppression of urine and respiratory paralysis 
(N. Y. Med. Record , Nov. 1886). I have found that injected into the 
jugular vein the volatile oil produces in the lower animals profound 
narcosis, with abolition of all reflexes, and finally death from paralysis 
of the respiratory centres. The dose of the volatile oil ( Oleum Myris- 
ticce , U.S.) is from two to five drops. 


STOMACHICS. 


645 


Pimenta. TJ.S.— Pimento., or Allspice , is the unripe berries of Eu¬ 
genia Pimenta, a tree, native of the West Indies. It contains a green 
fixed oil and a volatile oil (Oleum Pimentce, TJ.S.), the dose of which 
is two to five drops. 

Cardamomum. TJ.S.— Cardamoms are the fruit of Elettaria Car- 
damomum, which grows in the East Indies. They consist of tough, 
seemingly fibrous, generally more or less triangular capsules, contain¬ 
ing a number of small, hard, very aromatic seeds. The capsule is itself 
dry and tasteless. In commerce cardamoms are divided into three 
varieties, according to their length. According to Trommsdorf, the 
seeds contain, besides 10.4 per cent, of fixed oil, 4.6 per cent, of a color¬ 
less, highly aromatic, volatile oil. Cardamom is a very grateful aro¬ 
matic, much less stimulating and heating than most of the other sub¬ 
stances of its class. The dose of the tincture ( Tinctura Cardamomi —1 
to 6.6, TJ.S.) is half a fluidrachm. The compound tincture (Tinctura 
Cardamomi Composita , U.S.) is a very elegant addition to, or vehicle for, 
tonic medicines; dose, one to two fluidrachms. 

Zingiber. TJ.S.— Ginger is the dried rhizome or root-stock of Zin¬ 
giber officinale, growing in the East and West Indies. Green Ginger 
is the fresh rhizome. Black Ginger is the root-stock dried with the 
epidermis on; White or Jamaica Ginger is the same, deprived of its 
epidermis. The fresher ginger is, the greater is its power, and by time 
and exposure it becomes completely inert. Its active principles are a 
soft, acrid, aromatic resin, and a yellow, volatile oil. Ginger is much 
used in domestic medicine as a stimulant carminative in colic; given in 
hot water, it is also used as a sudorific and stimulant in the pain due to 
suddenly-suppressed menstruation. It is often added with advantage to 
other remedies in dyspepsia. The syrup (Syrupus Zingiberis , TJ.S.) is 
used only as a cordial drink or vehicle, in doses of from half a fluidounce 
to a fluidounce. The tincture (Tinctura Zingiberis —1 to 5, TJ.S.) is the 
most commonly employed; the dose is half a teaspoonful to a teaspoon¬ 
ful. The dose of the fluid extract (. Extractum Zingiberis Fluidum, TJ.S.) 
is ten drops. The oleoresin ( Oleoresina Zingiberis , TJ.S.) is employed as 
a stimulant addition to tonic pills; the dose is from half a minim to 
two minims. 

Piper. TJ.S. — Black Pepper is the unripe berries of Piper nigrum, 
a woody vine-like plant growing in the East Indies. White Pepper is 
the ripe berries stripped of their skin and dried. It is much inferior 
to the ordinary variety. The active principles of black pepper are a 
soft, acrid resin, a pungent, fiery, volatile oil, and piperine. 

In 1819 Oersted discovered Piperine (Piperina , TJ.S.), which crystal¬ 
lizes in colorless, glistening, four-sided, truncated prisms, of a neutral 
reaction, but capable of combining with acids to form salts. When 


646 


LOCAL REMEDIES. 


pure it is tasteless; but very commonly it has a burning taste, due to 
the presence of some of the volatile oil of pepper. The possession of 
very active antiperiodic properties has been claimed for piperine,* and 
it was for a time employed in intermittent fever; but it has fallen into 
complete disuse. The dose as an antiperiodic is four grains, repeated 
once or twice during the interval between the paroxysms. According 
to the observations of Professor H. Kronecker and of Herr Fliess, 
piperine in the frog paralyzes the peripheral ends of the sensory nerves 
(.Archiv fur Physiologie, 1882, p. 111). In the rabbit its action upon 
the sensory nerves is much less marked. The respiratory and pulse 
rates are greatly accelerated, and death is finally caused by cardiac 
arrest ( Ibid ., 1884). MM. Oechsner de Coninck and Pinet ( Comptes- 
Rendus Soc. Biolog. , Oct. 17, 1885, May 1, 1886, Oct. 30, 1886) have 
found that piperine, when brought in direct contact with the nerve, para¬ 
lyzes both motor and sensory fibres, and that there is no difference in 
the action of synthetical artificial piperine and the natural principle. 
Pepper is very largely used as a condiment; but, as its taste is more 
hot than aromatic, it is rarely used internally in medicine except as an 
addition to simple bitters or to antiperiodics, generally in the form of 
the officinal oleoresin (Oleoresina Piperis), the dose of which is a minim. 
In atonic dyspepsia the latter preparation is an excellent adjuvant to 
tonic pills. Dr. Schiffer is said (Fliess) to have used piperine success¬ 
fully in a case of vaginismus , by injecting 0.3 grain hypodermically 
near the vaginal entrance. In using piperine by hypodermic injec¬ 
tion it is of the utmost importance that it be free from the oil of 
pepper. 

Capsicum. U.S.—The U.S. Pharmacopoeia now recognizes only the 
small, less than an inch long, very fiery fruit of Capsicum fastigiatum, 
the African Pepper , or Chillies. The large, bright red, conical or ovate, 
comparatively mild peppers of the market are from C. annuum; they 
are sometimes known as West India peppers. Capsicum contains as its 
active principle an exceedingly acrid oleoresin. The name of Capsicin 
has been applied by different observers to the oil, to the resin, and to 
their combination, but should, I think, be dropped, as having no defi¬ 
nite meaning. 

Capsicum is a very powerful local irritant, its oleoresin when applied 
to the skin producing in a very few minutes intense pain and redness, 
and finally destroying the cuticle. In the alimentary canal it acts in 
a similar manner: thus, moderate doses produce merely a pleasant feel¬ 
ing of warmth in the stomach, while overdoses may cause gastrointes¬ 
tinal inflammation, with severe pain, as well as vomiting and purging. 
The chief use of Cayenne Pepper is as a condiment; yet it is often 
added with advantage to tonic pills to increase their immediate action 


* For a discussion of the subject, see Husemann, Die Pflanzewtoffe, p. 492. 



STOMACHICS. 


647 


on the stomach. When there is habitual feeble digestion, with flatu¬ 
lence, its free use on food may do good. In adynamic disease , especially 
as occurring among drunkards , capsicum is often very useful by stimu¬ 
lating the stomach up to the point of digesting food. Locally , either 
as the diluted tincture in a gargle, or applied in powder or tincture by 
means of a swab, it is useful in severe tonsillitis, especially in that ac¬ 
companying scarlet fever. 

Administration. —The dose of capsicum is four to five grains in pill 
form; of the officinal Oleoresina Capsid, which is to be preferred on 
account of its lesser bulk, from half a grain to one grain. The infusion 
(Infusum Capsici —Sss to Oj) is used as a gargle. The tincture ( Tinctura 
Capsici —1 to 20, U.S.) is employed locally, and is sometimes adminis¬ 
tered in half-fluidrachm doses to drunkards. 

Oleum Cajuputi. U.S.—The Oil of Cajuput is obtained from the 
leaves of Melaleuca Cajuputi, a tree growing in the Molucca Islands. 
This volatile oil is of a green color, a peculiar fragrant odor, and a 
burning, camphoraceous taste. It is not very irritating to the skin, 
and is exceedingly destructive to low forms of life, and consequently 
has been used as a parasiticide externally, and even internally against 
the Ascarides. I have never used it except as a carminative and aro¬ 
matic stimulant in cases of intestinal pain and spasm, and in serous 
diarrhoea. When employed in these affections in combination with chlo¬ 
roform, camphor, and opium, it is very efficient. As a counter-irritant, 
it has been used in rheumatism; as a stimulant to the skin, in psoriasis, 
acne rosacea, and pityriasis. The dose internally is from ten to fifteen 
drops. 

Oleum Sassafras. U.S.—The Oil of Sassafras is enormously used 
in the arts on account of its cheapness and pleasant flavor. It is capa¬ 
ble of producing very marked narcotic poisoning (case, Trans. Med.- 
Chir. Faculty Maryland, 1884, 288), and is said to act upon the lower 
animals as a convulsant and narcotic. Dr. John Bartlett ( Chicago Med. 
Journ ., Dec. 1885) asserts that it is capable of producing uterine con¬ 
tractions, and reports cases of abortion caused by it. 

Aurantii Amari Cortex.—Bitter Orange Peel, U.S.—The fluid 
extract ( Extractum Aurantii Amari Fluidum, U.S.) and the tincture 
( Tinctura Aurantii Amari) may be given respectively in doses of twenty 
minims and a fluidrachm. Aurantii Dulcis Cortex — Sweet Orange 
Peel, U.S.—Of the syrup (Syrupus Aurantii , U.S.) the dose is a dessert¬ 
spoonful, of the tincture ( Tinctura Aurantii Dulcis, U.S.) a tablespoonful. 
The orange peels are themselves scarcely medicinal, but are officinal as 
affording preparations much used as vehicles. Limonis Cortex, U.S., 
or Lemon Peel (Spiritus Limonis, U.S.), is also used for flavoring-pur¬ 
poses. 


648 


LOCAL REMEDIES. 


Aurantii Flores. —The flowers of the orange are officinal for the 
preparation of Orange Flower Water,—Aqua Aurantii Forum, U.S.,— 
which is used as an elegant vehicle, free from medicinal properties. 

The fruits of the following umbelliferous plants, Fceniculum vulgare, 
Carum Carui, Coriandrum sativum, Pimpinella Anisum, are officinal 
under the respective names of Fceniculum (. Fennel), Carum (Caraway ), 
Coriandrum ( Coriander ), Anisum (Anise). They all depend for their 
virtues upon volatile oils which are officinal. The oil of anise of 
commerce is chiefly the product of a Chinese tree, the Illicium Anisa- 
tum, or Star Anise, from whose five- to ten-rayed capsular fruit it is 
obtained by distillation. The Aqua Fceniculi and Spiritus Anisi are 
officinal. All of these fruits and their preparations may be used as 
carminatives and stomachics. 

The herbal portions of the following mints are officinal: Lavandula 
vera, Rosmarinus officinalis, Salvia officinalis, Mentha piperita, Mentha 
viridis, Melissa officinalis. They are respectively known as Lavender 
{Lavandula), Rosemary ( Rosmarinus), Sage (Salvia), Peppermint (Mentha 
piperita), Spearmint (Mentha viridis), and Balm (Melissa). The most 
important preparations of them are as follows: Spiritus Lavandulce 
Compositus — Compound Spirit of Lavender, a very elegant and agreeable 
stomachic and cordial; dose, a fluidraehm to half a fluidounce. Aqua 
Menthce Piperitce — Peppermint Water, and Aqua Menthce Viridis — Spear¬ 
mint Water, both very frequently used as vehicles. Spiritus Menthce 
Viridis and Spiritus Menthce Piperitce — Essence of Spearmint and Essence 
of Peppermint, used as carminatives, in doses of from ten to twenty 
drops. The oils of lavender,* peppermint, and spearmint are also 
officinal, and may be used in doses of from three to ten drops as car¬ 
minatives. Sage contains tannin. 

Water of rosemary (Aqua Rosmarini, IJ.S.) has long been believed 
to have especial influence upon the skin, and in cases of acne a lotion 
composed of a pint of this water and an ounce of the flowers of sulphur 
is often extremely effective. 

The volatile Oil of Gaultheria (Oleum Gaultherice, U.S.) is used for 
flavoring-purposes. Its physiological and therapeutic properties are 
entirely different from those of other volatile oils, and will be found 
fully discussed under the head of Salicylic Acid. Calamus, the rhi- 

* MM. Masoin and Bruylant have studied to some extent the physiological action of the 
oils of lavender, rosemary, marjoram, and aspic ( Lavandula spica L.) (Bull. Acad. Roy. MSd. 
de Bruxelles, 1879, 558; see, also, Schmidt’s Jahrb., clxxx. 123). In frogs they caused 
generally paralysis, with loss of reflex activity, the muscles being intact, and the sensory 
nervous apparatus being affected before the motor. Upon the higher animals a similar effect 
was produced, except that oil of rosemary caused epileptiform convulsions. Oil of Peppermint 
(M. piperita) has been studied by S. D. Markuson ( Inaug. Biss., Halle, 1877; Schmidt’s 
Jahrb., clxxx. 122), who finds that while very small doses increase, larger ones decrease 
the blood-pressure and lower the bodily temperature. 



STOMACHICS. 649 

zome of Acorus Calamus, also contains a volatile oil, and its infusion 
is sometimes used as a carminative. 


AROMATIC BITTERS. 

ANTHEMIS. U.S.—CHAMOMILE. 

j Roman or true Chamomile is the dried flowers of Anthemis nobilis, 
a composite of Europe. They are sometimes single, sometimes double. 
The single are more aromatic than the double florets. Chamomile con¬ 
tains a bluish or sometimes greenish volatile oil, a bitter principle, and 
a small amount of tannin. Matricaria, U.S., or German Chamomile, is 
the flowers of Matricaria Chamomilla, which are decidedly smaller than 
those of the ordinary chamomile, and have a stronger, less agreeable 
odor and taste. Their volatile oil is very similar to that of chamomile. 

Therapeutics. —An excellent stimulant tonic, especially useful in 
convalescence. The dose of the infusion (Infusum Anthemidis —§ss to 
Oj) is one to two wineglassfuls before meals. 

Serpentaria. U.S.— Virginia snakeroot is the root of Aristolochia 
Serpentaria and of A. reticulata, small herbal plants of the United 
States. It occurs as fine brittle rootlets attached to a small head, of a 
camphoraceous odor and taste, and contains a volatile oil, a yellowish- 
green resin, and a bitter principle. It is an elegant stimulant tonic, 
especially useful as an adjuvant to more powerful bitters. In overdose 
it is said to cause vomiting, and even purging. The dose of the tincture 
(Tinctura Serpentarice —1 to 10, U.S.) is one to two fluidraehms; of the 
fluid extract (Fxtractum Serpentarice Fluidum, U.S.), twenty drops. 

Cascarilla, U.S., is the bark of Croton Eluteria, a shrub growing 
in the West Indies. This bark occurs in quills or rolled pieces, and is 
to be distinguished by its outer grayish and inner deep-chocolate sur¬ 
face, by its spicy bitter taste, and by the pleasant musk-like odor which 
it gives forth while burning. It contains tannin, volatile oil, and cas- 
carillin, a neutral, bitter, crystallizable principle. Its therapeutic action 
is very similar to that of serpentaria. The dose of the infusion (Jn- 
fusum Cascarillce —§i to Oj) is a wineglassful. 


FAMILY II—EMETICS. 


Emetics are those drugs which are employed in the practice of 
medicine for the purpose of producing emesis, or vomiting. The 
mechanism of vomiting has been so frequently written upon, and has 
so little connection with the application of emetics, that it is not neces¬ 
sary here to enter upon an elaborate discussion of it.* Suffice it to 
state that emesis is the result of a very complicated series of actions, 
in which the chief expulsive force is supplied by the abdominal muscles 
and the diaphragm,—the stomach, however, participating in the general 
contraction, and not being, as some have thought, entirely passive. The 
exact relations and functions of the various nerves concerned are not, 
I think, fully made out. It has been generally believed that the pneu- 
mogastrics were the afferent nerves, and that, although emetics intro¬ 
duced into the circulation after their section vomited, yet irritation of 
the gastric mucous membrane was not capable of so doing. But Schiff 
found in his experiments that, even when the nerves were cut in the 
neck, the introduction of semi-solid food into the stomach gave rise to 
efforts at vomiting, which were in some cases successful; and Maclagan f 
has obtained similar results with the sulphates of zinc and copper. 
Moreover, I have invariably failed to induce vomiting with veratria, 
even when given immediately after section of the par vagum. Evi¬ 
dently, further investigations are needed. 

Vomiting occurs under two provocations, or in two manners. Thus, 
a mental impression, or a disordered state of the blood, may influence 
the nerve-centres directly, and emesis, spoken of as centric , results; or 
a peripheral irritation in the stomach itself, or in some other organ, as 
in the kidneys, may induce vomiting precisely similar in the method of 
its production to the more ordinary reflex movements; such vomiting 
is called reflex or excentric. 

Emetics produce their results in both of these methods. Thus, 
tartar emetic has been believed to affect the centres directly, so as to 
cause centric vomiting, while sulphate of copper has been believed to 
irritate the mucous membranes of the stomach, so as to produce reflex 


* For a very elaborate general discussion on emetics, see Professor Joseph Carson, Phila. 
Med. Times, June, 1872; also, Dr. D’Ornellas, Bull. Tliirap., lxxxiv. 193. 

t The Action of Medicines in the System, by F. AY. Headland, M.D., Arner. ed., 1839, p. 

110 . 


650 




EMETICS. 


651 


vomiting. Recently much doubt, however, has been thrown upon the 
old views, and it is probable that most emetics have a double influence. 
Thus, the purging of veratria or of tartar emetic is almost certainly 
connected with its elimination, and is probably due to a direct action 
of the circulating poison upon the intestinal mucous epithelium, gland- 
cells, and peripheral nerves. It seems a priori almost a necessity that 
the vomiting caused by these poisons is produced in the same way as 
the purging. Dr. D’Ornellas has found that when emetine is injected 
into the veins of animals the vomiting occurs simultaneously with the 
elimination of the alkaloid from the gastric mucous membrane, and 
asserts that Kleimann and Simonowitsch have determined the same 
thing with antimony.* Further (see page 389), antimony seems to 
cause vomiting partly by acting upon the centres, partly by irritating 
the peripheral nerve. Irritant emetics are more prompt than those 
which chiefly affect the nerve-centres, and act more certainly when the 
nerve-centres are obtunded, as in narcotic poisoning; they always cause 
less nausea and general systemic disturbance than do the centric emetics. 

Another evident practical fact is, that while centric emetics will act 
in whatever way they are introduced into the system, the mechanical 
emetics must be exhibited by the stomach. Thus, apomorphine may be 
given by hypodermic injection, but mustard must be taken by the mouth. 

A very curious property of emetics has been pointed out by Dr. 
E. Harnack (Archiv f. Exper. Path. u. Pharm., iii. 44), who, as the 
result of an elaborate investigation, affirms as a law that all specific 
emetic substances destroy, even when in relatively small dose, the ex¬ 
citability of striated muscular fibre. Dr. Ilarnack seems to establish 
the general truth of this; but that it is a universal law seems scarcely 
probable, and the connection between the two properties is very obscure. 
According to H. Kobert (Arch. f. Exper. Path. u. Pharm ,., xv. 36), anti¬ 
mony has an effect only when the contact is prolonged. 

In regard to the phenomena of vomiting, there are a few points to 
which it is necessary here to call attention. First of these is the fact 
that nausea always produces, or is accompanied by, muscular relaxation. 
Vomiting may take place, as from mustard, without much relaxation; 
but when it is accompanied by much nausea the whole system is as it 
were unbent, the skin relaxed and bedewed with perspiration, the pulse 
soft and feeble, the muscular system limp and incapable of exertion, the 
mental acts almost suspended. During violent vomiting the blood is 
driven to the head, so that the whole exterior of the cranium, and prob¬ 
ably the interior also, becomes very much congested. The abdominal 
circulation is very much affected, and the blood is as it were squeezed 
out of the portal vein and its tributaries. The matters rejected consist 


* Copper has been thought to be a purely mechanical emetic, but the experiments of 
Brunton and West {St. Bartholomew’s Hosp. Rep., 1876) show that a peptone of copper in¬ 
jected into a vein causes violent vomiting. Those remedies whose irritant powers are great 
may still well be considered as “ mechanical emetics.” 



652 


LOCAL REMEDIES. 


of the contents of the stomach, and, in repeated vomiting, also those 
of the duodenum. The secretion from the gastric mucous membrane 
is very much enhanced, and without doubt is more or less modified. 
Bile in ejecta is to be recognized by the green color and the bitter 
taste, or more infallibly by testing with the proper reagents. 

The indications for the use of emetics are as follows: 

1. To unload the stomach. —For this purpose they are employed in 
poisoning; in the existence of crude articles of food or indigestible 
substances in the stomach; or in the presence of acrid, perverted secre¬ 
tion. The symptoms induced by irritating materials in the stomach 
are various, and sometimes it requires a good deal of tact or experience 
to recognize their cause. Among them may be mentioned a feeling of 
weight or load in the stomach, gastric distress, or severe cramp or spas¬ 
modic pains, with or without some nausea and retching. In other cases 
no local manifestations of trouble may be present. Thus, convulsions 
in children are very frequently the result of gastric irritation, and are 
at once relieved by emptying the stomach. In adults, apoplectiform 
coma may offer a similar history. Occasionally urticaria , or hives, and 
not rarely severe headache , have a similar origin, and require a similar 
treatment. 

2. To affect the abdominal viscera and circulation. —Emetics have been 
recommended by some in congestions of the spleen; but evidence is want¬ 
ing as to their power to affect materially other viscera than the liver. 

In congestion of the hepatic and portal circulation, not dependent upon 
organic cause, and in the condition of digestive derangement known as 
biliousness, they are often of service. In catarrhal jaundice they may 
effect much good by causing dislodgement of the mucus plugging the 
ducts. They have been employed in cases of biliary calculi; but the 
chances of forcing out the calculus by external violence are probably 
no greater than those of lethal rupture of the gall-bladder. 

3. To dislodge substances from the respiratory passages. —For this 
purpose emetics are sometimes used when foreign bodies have found 
entrance into the larynx; but it is chiefly in membranous croup that the 
present indication is met with. The emetics chosen for this purpose 
should be such as act with violence without producing much nausea or 
systemic disturbance: the mechanical emetics are therefore the best. 

4. To produce muscular relaxation. —The introduction of ansesthesia 
has rendered the use of emetics to meet this application almost obso¬ 
lete. Occasionally, however, in asthmatic or other spasmodic affections 
of the respiratory organs, emetics are still employed. For this purpose 
the drugs causing much nausea are preferred. In adults, lobelia is the 
best; in children, ipecacuanha. Nauseating rather than emetic doses 
should be employed. 

5. To lessen arterial action and reduce inflammation. —Almost the sole 
disease in which advantage can be derived from this use of emetics is 
acute bronchitis in its early stages. In very many cases a “ cold on the 


EMETICS. 


653 


chest” in its outset may at once be subdued by ipecacuanha, or, better 
still, tartar emetic: small doses should be given at short intervals, to 
produce continuous nausea, terminating after a time in vomiting. This 
method of cure is so disagreeable, although very efficacious, that patients 
will rarely submit to it, unless, as sometimes in the case of public speakers, 
relief within a short period of time be a matter of great importance. It 
should be added that the cure is wrought in these cases not merely by the 
lessening of arterial action, but also by the induction of free bronchial 
secretion. 

6. To create a shock to the system .—Under this head may be included 
several empirical uses of emetics, in which advantage is gained, but in 
a method which is not very clear. Thus, in epileptic attacks, when the 
fits have a tendency to recur every few minutes, the unconsciousness 
persisting, it may be, for hours, emetics will sometimes break up the suc¬ 
cession of disordered nervous action. Again, it is said that an ague-fit 
can be set aside by an emetic given just before its expected recurrence. 

Contra-indications .—The chief contra-indications to the use of emetics 
are the existence of congestion of the brain, and of gastric inflammation. 
Advanced pregnancy, and hernia, while they do not positively contra¬ 
indicate the use of emetics, should cause great caution to be practised 
in their employment. 

Administration. —Emetics should, as a general rule, be given in a 
full dose, so as to avoid unnecessary repetition, and should be adminis¬ 
tered dissolved in water or in syrup. Their action should be assisted 
by frequent and copious draughts of tepid water, which also have the 
advantage of rendering the vomiting less painful. When for any reason 
protracted nausea is desired, the doses should be small and repeated at 
short intervals. 

Hyperemesis may advantageously be divided into two varieties : first, 
such as is due to overdoses of depressing centric emetics; second, such 
as arises from irritation of the stomach, as by mechanical emetics. The 
treatment of the first of these consists in the enforcement of absolute 
quiet in the horizontal position, the free use of opium enemata, the 
application of counter-irritants to the epigastrium, and the use of alco¬ 
holic stimulants. The latter should be given in hot water, and should 
not be too much diluted. I have seen raw brandy arrest at once the 
most alarming centric emesis, after the failure of other methods. Crea- 
sote, chloroform, or chloroform and volatile oils, are sometimes of value 
in this form of hyperemesis. When excessive vomiting is due to some 
irritant emetic, the stomach should be thoroughly washed out by large 
draughts of warm mucilage, opium given by the rectum, a mustard 
plaster or blister, or, often better still, leeches, applied to the epigas¬ 
trium, and no medicine at all be taken into the inflamed viscus. The 
swallowing of small pieces of ice is sometimes of service. If these 
remedies fail, the treatment of this form of hyperemesis soon resolves 
itself into that of gastritis. 


654 


LOCAL REMEDIES. 


VEGETABLE EMETICS. 

IPECACUANHA. U.S. 

The root of Cephaelis Ipecacuanha, a small, shrubby plant, grow¬ 
ing in Brazil, where the 'drug is gathered by the Indians, to be ex¬ 
ported in large bales or bags. Ipecacuanha occurs in pieces of two or 
three lines in thickness, variously bent and contorted, marked on their 
surface with numerous prominent rings, and composed of an outer, 
thick, active, hard, and horny cortex, and an inner, light, inert, woody 
centre. Varieties of ipecacuanha—the red, the gray , and the brown — 
have been formed from the color of the bark, but the distinction is 
trivial. The root has very little odor, but the brown powder has a 
decided and peculiar smell, and in some persons excites sneezing, or 
even violent asthmatic dyspnoea. The taste is bitter, acrid, and nause¬ 
ous. The active principle is Emetine , an alkaloid first discovered by 
Pelletier in 1817. The cortex also contains small quantities of ipecac- 
uanhic acid, which is related to tannic acid. Pure emetine is a white, 
unc-rystallizable, odorless powder, of a bitter, burning taste, soluble in 
one thousand parts of water at 50° C. (Lefort), freely soluble in dilute 
and absolute alcohol, in chloroform and benzole, scarcely so in ether. 
Its solution in acidulated water, according to Dragendorff, has a de¬ 
cided blue fluorescence. Its salts are, according to Pelletier, uncrys- 
tallizable. Concentrated sulphuric acid turns it a dirty brown, nitric 
acid a yellowish brown. Pure emetine is very difficult to prepare, and, 
according to Mr. Williams (St. Bartholomew's Hospital Reports , vol. v.), 
only two grains of it can be obtained from an ounce of the root. The 
ordinary impure alkaloid of the shops occurs in brownish-red, trans¬ 
parent, very deliquescent scales, which are very soluble in water. 

Physiological Action. —Locally applied, ipecacuanha is a decided 
irritant, manifesting its action not only upon mucous membranes and 
upon denuded surfaces, but even, when used by inunction, producing 
an eruption upon the sound skin. According to Dr. Dyce Duckworth, 
this eruption consists at first of small, discrete pustules with a rather 
large areola; afterwards, if the application be persisted in, of large 
pustules, followed by severe ulceration. When exhibited in small re¬ 
peated doses to man, it produces malaise, with nausea, and perhaps an 
increase of the secretions of the salivary glands and of the mucous 
membrane of the bronchial tubes and of the stomach. In larg-e 
amounts it causes vomiting, accompanied by only a moderate amount 
of nausea but by a decided increase of the secretions mentioned above. 
The vomiting, even when very large amounts are taken into the stom¬ 
ach, is not apt to be severe, nor the prostration marked,—no doubt be¬ 
cause the excess of the drug is rejected before absorption. After large 
doses of emetine this mildness of action, in all probability, would not 
be present: certainly animals are readily killed by the alkaloid. Al- 


EMETICS. 


655 


though ipecacuanha was made known in 1649 by Piso, and although it 
has been enormously used since its introduction into Europe in 1672, its 
physiological action is not as yet well made out. That the active prin¬ 
ciple is absorbed, and that the vomiting is so produced, is shown by 
the experiments of Orfila ( Toxicologie , i. 651), and of Drs. Dyce Duck¬ 
worth, D’Ornellas, and Pecholier, who found that vomiting followed 
the hypodermic use of emetine in dogs and cats. If it be true, as is 
affirmed by D’Ornellas, that the emetine produces vomiting much more 
slowly when thrown into the veins than when given by the stomach, 
it would seem that the local irritant action of the drug efficiently favors 
emesis. 

According to Dr. D'Ornellas ( Gaz. Med., 1873, p. 537), Merck's com¬ 
mercial emetine in toxic doses (0.03 milligramme) produces in frogs 
dryness of the skin, swelling of the abdomen, diminution of the cir¬ 
culation and respiration, increased rather than diminished sensibility, 
muscular feebleness deepening into abolition of voluntary movement, 
with at first increased and afterwards diminished reflex activity, and 
finally death from failure of respiration ; the heart continuing to beat 
often for many hours. In mammals the symptoms induced by the 
poison in large doses are very similar to those just detailed, except 
that emesis is usually violent, but in some cases it is wanting. 

Circulation. —The action of the drug upon the circulation has not as 
yet been clearly made out. Any action upon the heart-muscle must be 
a very feeble one, since D’Ornellas states that although the frog’s heart 
is finally arrested in diastole, yet it retains often for many hours its 
irritability. It has been supposed by some that the drug acts especially 
upon the vaso-motor system; but evidence of this has not as yet been 
brought forward. Polichronie, it is true, asserts (£’ Ipecacuanha, Paris, 
1874) that dryness and paleness of the intestinal mucous membrane 
are very apparent in mammals poisoned with emetine, and Chouppe 
(Le Progres Med., 1874, p. 425) has observed the same thing; but this 
is an absurdly slight ground for believing that emetine causes vaso¬ 
motor spasm. Pecholier found in a single experiment that the drug 
abated very decidedly the arterial pressure, but Dr. D’Ornellas found 
that emetine neither depresses nor increases the blood-force; and in a 
series of elaborate experiments by Dr. Dyce Duckworth the alkaloid 
failed to influence materially the circulation, at least until very late in 
the poisoning. The pulse-rate was not constantly affected ; sometimes 
it was apparently lowered, sometimes it remained about the same, and 
sometimes it was seemingly increased. The effect of an overwhelming 
dose was, however, marked. In one case immediate suspension of car¬ 
diac action followed injection into the jugular vein; in another dog, in 
a minute and a half after half a grain of emetine the arterial pressure 
descended from 135 to 20, and in a moment the animal was dead of car¬ 
diac paralysis. Dr. Foulkrod ( Phila. Med. Times , viii. 554) has noticed 
a steady fall of arterial pressure produced both before and after section 


656 


LOCAL REMEDIES. 


of the cord of all the cardiac nerves. There is no proof that emetine 
ever causes vaso-motor spasm, while it is certain that toxic doses directly 
paralyze the heart; therapeutic doses probably have no decided direct 
effect upon the circulation. 

Respiration. —According to D’Ornellas, Pecholier, and Foulkrod, 
emetine in toxic doses usually kills by arresting the respiration; but 
in many of Dyce Duckworth’s experiments (/SI Bartholomew s Hosp. 
Rep ., v., vii.) the death was certainly the result of cardiac paralysis, 
possibly because the poison was thrown directly into the circulation,— 
i.e., into the heart. 

Nervous and Muscular Systems. —Upon the cerebrum ipecacuanha 
exerts no perceptible influence; but, as both D’Ornellas ( loc. cit ., p. 538) 
and Pecholier (loc. cit., p. 57) have found that after death from emetine 
in the frog both nerves and muscles retain their susceptibility to feeble 
galvanic currents, the paralysis which the poison produces is probably 
spinal. D’Ornellas and Pecholier are in opposition in regard to the 
action of the alkaloid upon sensibility, the one affirming that it is not, 
the other that it is, affected. 

Temperature. —Pecholier, Dyce Duckworth, and D’Ornellas all state 
that in emetine-poisoning there is a distinct fall of temperature in the 
mouth and on the surface of the body, but that in the intestines the tem¬ 
perature either remains stationary or, more commonly, rises; D’Or¬ 
nellas affirms that it always rises decidedly. This rise is probably, as 
D’Ornellas believes, local, and due to the action of the poison upon the 
intestinal tract. 

Pulmonic and Digestive Organs. —The post-mortem results obtained 
in animals poisoned with ipecacuanha are diverse, but affect chiefly 
either the lungs or the digestive tract. Pecholier, in his earlier experi¬ 
ments, found great paleness of the lungs, with intense hyperaemia of 
the stomach and the upper half of the intestines, but in some of his 
later experiments the lungs were profoundly influenced. Dyce Duck¬ 
worth especially noted intense hyperaemia of the lungs, which were in 
some places emphysematous, but in other portions collapsed and even 
affected with true consolidation. The lesions were much less marked 
in the intestines than in the lungs, which resembled very closely those 
taken from the bodies of animals killed by section of the vagi. The 
pulmonic lesions were found to be most intense in the rabbit; the intes¬ 
tinal, in the dog, cat, and guinea-pig. Magendie forty years ago noted 
the pulmonic lesions of emetine-poisoning, and D’Ornellas has likewise 
recorded them, but has also seen cases in which ischamiia of the pulmo¬ 
nary tissue was found after death. It is evident that the poison has an 
especial action upon both lungs and intestines; but why the pulmonic 
lesions should so vary is not at present known. The occurrence of 
changes in the pulmonary tissues is in accord with the results of clin¬ 
ical experience, which teaches most decidedly that ipecacuanha has an 
action upon the pulmonary mucous membranes. After section of the 


EMETICS. 657 

cervical vagi, Dr. Dyce Duckworth found that emetine failed to cause 
vomiting. 

Clinical experience also shows that ipecac acts upon the digestive 
tract. Whether given in large or in small doses, it is very apt in man 
to increase and modify the intestinal secretions. It probably influences 
the liver, since Pecholier ( Gazette Medicate, 1862) affirms that in animals 
killed by it no hepatic glucose can be found. Moreover, great advan¬ 
tage from its use may often be obtained in the condition known as 
“ biliousness.” In “ bilious dysentery” it will often produce large tarry 
discharges; and I have seen a change in the color of the stools follow 
its use in catarrhal jaundice. The mechanical effect of the vomiting 
induced by it in these cases, however, must not be lost sight of; yet it 
does not seem to me at all sufficient to account for the results, especially 
as some observers state that the effects noted are produced even when 
little or no vomiting occurs. It has been proved by D’Ornellas and 
Pecholier that when emetine is introduced into the circulation or into 
the cellular tissue it escapes with the secretions of the stomach and 
bowels; so that the changes which are provoked in these organs are 
evidently connected with the elimination of the drug. 

Therapeutics. —The most ordinary use of ipecacuanha is as an 
emetic. Whenever it is desired to unload the stomach or to act by 
emesis upo'n disease, without inducing much prostration, this drug com¬ 
mends itself by its safety and efficiency. In narcotic poisoning it is less 
certain than the “ mineral emetics,” but, as it produces no irritation of 
the stomach, can be given more freely than they can, and is constantly 
used as an adjuvant to them. It is especially useful in the diseases of 
children, never causing the serious depression which tartar emetic is so 
apt to produce. When, however, very violent emesis is desired, as in 
membranous croup, other emetics, such as zinc or alum, are to be pre¬ 
ferred, on account of the greater force of their action. 

In sick stomach of nervous origin, such as occurs in pregnancy, minute 
doses of ipecacuanha have so often met with success that there can be 
no doubt of their value. One drop of the wine in a teaspoonful of 
water should be given every hour. The use of ipecacuanha as an ex¬ 
pectorant will be spoken of under that heading. 

One of the most important uses of ipecacuanha is in acute dysentery, 
—all forms of which have been treated with it with asserted advantage. 
I think, however, its beneficial action is best seen in “ bilious dysentery ” 
and in “ malignant dysentery ,” as is indicated by the fact that its use is 
most common in tropical climates. In “ sthenic inflammatory dysentery ” 
it seems to be less available; although even in this it has been strongly 
advocated by some. Dr. Chouppe {Bull. Therap ., June, 1874) com¬ 
mends injections of ipecacuanha highly in choleriform diarrhoea of chil¬ 
dren, and in tuberculous diarrhoea, and Polichronie not only corroborates 
him, but also affirms that the same treatment is of great value in col¬ 
liquative sweats. In a very valuable clinical paper {Atlanta Med. and 

42 


658 


LOCAL REMEDIES. 


Surg. Journ ., 1875) Dr. A. A. "Woodhull brings forward very strong 
evidence of the value of the remedy not only in dysentery, but also in 
choleriform diarrhoeas. The drug appears to exert a direct influence 
upon the hepatic and intestinal glands, and may be tried with great 
hope of success wherever there is decided glandular derangement. 

In catarrhal jaundice , and in intermittents or remittents accompanied 
by congestion of the portal circulation, ipecacuanha is often very 
serviceable. 

As a haemostatic , ipecacuanha has been recommended by Trousseau, 
and Pecholier asserts that in haemoptysis it is a specific {Bull. Therap., 
xcvii. 49).* It has been given with asserted advantage in flooding 
after child-birth, and Dr. Carrigen claims for it oxytocic powers {N. Y. 
Med. Journ., 491, 1878). 

Administration.— As an emetic, ipecacuanha is generally adminis¬ 
tered in powder, thirty grains being given every fifteen or twenty min¬ 
utes until the desired effect is produced. For a child a year old the 
emetic dose is five grains. Its action should be aided and hastened by 
large draughts of lukewarm water. As a nauseant the dose is from 
two to five grains. In dysentery it is generally best to begin with a 
full emetic dose, or with ten grains repeated every half-hour until 
emesis is produced. Two or three hours after vomiting, fifteen drops 
of laudanum should be exhibited, followed in twenty minutes by five 
to ten grains of ipecacuanha in pill-form; this should be repeated 
every two or three hours, the amount of the opium being lessened, and 
that of the ipecacuanha increased, according to circumstances. The 
object is to have as much of the ipecacuanha retained as possible. 
Another plan is to give larger doses (twenty grains), repeated every 
two, four, or six hours, mustard being applied to the epigastrium and 
opium exhibited as before ; and it is said that after two or three doses 
tolerance is established and the drug retained. In India, enemata of 
ipecacuanha are often employed, either as a substitute for or an adjuvant 
to its use by the mouth. This treatment has recently been imitated by 
Chouppe and others, and has been practised quite extensively in my 
ward in the Philadelphia Hospital. It is undoubtedly frequently effi¬ 
cient in abdominal complaints, and the gastric symptoms are almost 
always avoided. In chronic cases the repetition of the enemata some¬ 
times produces so much local irritation as to forbid their continuance. 
I have been accustomed to give a scruple of the powder with starch 
and laudanum, repeated every four hours. A decoction of the drug is 
to be preferred, as probably causing less local irritation and being more 
thoroughly absorbed. To an adult, Chouppe gives two injections of a 
decoction daily, each lavement representing two and a half drachms 
of the drug. 

As a counter-irritant, ipecacuanha is rarely used in this country; 


* Consult Pacific Med. and Surg. Journ., 1876. 



EMETICS. 


659 


but in England a liniment is employed composed of four parts of the 
powder to fourteen parts of olive oil. 

The preparations for internal use are: a syrup (Syrupus Ipecacuanhas , 
U.S.— fld. ext. 5 to 100),—dose, as an emetic for an infant, one to two 
teaspoonfuls; a wine (Vinum Ipecacuanhas, U.S.,—fld. ext. 1 to white 
wine 7 ), —dose, the same as the syrup; and a fluid extract (Extractum 
Ipecacuanha Fluidum, U.S.),—dose, as an emetic for an adult, thirty 
drops. Trochisci Ipecacuanhce , U.S., Trochisci Morphines Ipecacuanhas , 
U.S., are used in catarrh of the throat as a local application. 

Emetine is not officinal, but has been used by Dr. Dyce Duckworth 
(.London Pharmaceutical Journal , March. 1872) and his colleagues in 
doses of from one-twelfth to one-sixth of a grain. 

SANGUINARIA—BLOODROOT. U.S. 

This is the rhizome of an indigenous perennial herb, Sanguinaria 
Canadensis. It occurs in pieces two or three inches long, reddish brown 
externally, a bright somewhat orange red internally, and, when fresh, 
full of a similarly-colored juice. It contains two asserted alkaloids, 
Puccine and Porphyroxine , besides an alkaloid, first discovered in it by 
Dr. Dana in 1829 and named by him Sanguinarine, but which is iden¬ 
tical with the alkaloid of Chelidonium majus,— Chelerythrine. As the 
latter was not discovered by Probst until 1839, it is obvious that the 
name sanguinarine has the priority and should be adopted. Sangui¬ 
narine occurs in colorless stars or groups of fine needle-like crystals, 
tasteless when dry, of a sharp burning taste when moistened with 
alcohol, very irritating to the nasal mucous membrane, and uniting 
with acids to form brilliant red, mostly soluble, salts. 

Physiological Action. —In full doses sanguinaria acts upon man as 
a harsh emetic, and in overdoses, according to Dr. Tully, it produces, 
with the vomiting, burning at the stomach, faintness, vertigo, dimin¬ 
ished vision, general insensibility, coldness, extreme reduction of the 
force and frequency of the pulse, together with great irregularity of 
action and often palpitation of the heart, great prostration of muscular 
strength, and sometimes a convulsive rigidity of the limbs. Fatal 
poisoning of several persons occurred by it at Bellevue Hospital; but 
the only symptoms recorded are “ racking, burning pains, and tor¬ 
menting thirst.” 

The only physiological study of the drug as yet made is that of Dr. 
Robert Meade Smith (Amer. Journ. Med. Sci., Oct. 1876). He finds that 
sanguinarine causes in mammals vomiting, purging, profuse salivation, 
followed by collapse, dilated pupils, with sometimes clonic convulsions, 
and death from asphyxia. As the result of numerous experiments, he 
concludes that the convulsions are spinal, but associated with decreased 
reflex excitability, which is at first due to an excitation of Setschenow’s 
centre, but afterwards to a depression of the spinal centres; and that 
there is a progressive lowering of the pulse and arterial pressure after 


660 


LOCAL REMEDIES. 


large doses, caused partly by a direct action upon the heart, partly by 
paresis of the vaso-motor centres. Moderate doses of sanguinarine Dr. 
Smith finds to irritate at first the vaso-motor centres, and so produce a 
primary rise of the arterial centre. Muscular contractility is reduced 
by it, salivation greatly increased, and the respiration progressively ren¬ 
dered slower and shallower by a direct action upon the centre. 

Therapeutics. —As an emetic, sanguinaria has fallen into well- 
deserved disuse. Indeed, I have never known of its employment ex¬ 
cept as a stimulant expectorant in obstinate bronchitis , and even then 
with doubtful advantage. 

Administration. —The crude drug is very rarely used ; the emetic 
dose of the powder is from ten to sixty grains. Professor E. P. Thomas, 
in experiments upon himself and others with the alkaloid, found that 
in a dose of from one-eighth to one-twelfth of a grain it acted as an 
expectorant, without disturbing the stomach; one-sixth or one-fourth 
of a grain given every two or three hours generally nauseated, the 
emetic dose being half a grain repeated every ten minutes. One-sixth 
of a grain every three hours, in the course of two or three days, re¬ 
duced the pulse from five to twenty-five beats per minute. The ex¬ 
pectorant dose of the tincture (Tinctura Sanguinarice, —1 to 6.6, U.S.) is 
gtt. xx to xl; of the vinegar (Acetum Sanguinarice , U.S.), fifteen to thirty 
minims; of the fluid extract ( Extractum Sanguinarice Fluidum, U.S.), 
three to five minims. 

APOMORPHINE HYDROCHLORAS—HYDROCHLORATE OF 

APOMORPHINE. U.S. 

Apomorphine was discovered by Dr. Matthieson and C. E. A. Wright 
( Proceed . Roy. Soc., xvii. 455), who made it by the action of a strong 
solution of hydrochloric acid upon morphine. A probably better 
method of preparation is that of E. L. Mayer ( Berichte Deutsch. Chem. 
Gesell. , Berlin, 1871, iv. 121), in which the morphine is treated with 
a solution of chloride of zinc at 120° C. Apomorphine occurs as a 
snow-white powder, which is permanent when dry, but when moist 
soon becomes green. Its solution suffers this change, which is probably 
an oxidation, in a few minutes by heat (Matthieson and Wright), and 
in a few hours at ordinary temperature; and in the course of some 
weeks the green tint deepens into a black. Bichromate of potassium 
turns it a dense yellow orange; bichromate of potassium and concen¬ 
trated sulphuric acid make a dark red with it; and with neutral chlo¬ 
ride of iron it strikes an amethyst color. It differs from morphine in 
being soluble in cold water. The officinal salt is soluble in six parts of 
water. 

Physiological Action. —In doses of from one to five milligrammes 
in frogs apomorphine causes at first a stage of restlessness, which, after 
a time, yields to an increasing sluggishness and muscular weakness that 
may end in real or apparent death. In some instances there are violent 


EMETICS. 


661 


convulsions, both clonic and tonic in character.* Sometimes recovery 
occurs after both respiration and cardiac action have apparently ceased. 

When small doses (1 to 2 milligrammes) of the alkaloid are given to 
dogs, vomiting, without any other decided symptoms, is induced; after 
slightly larger amounts, the vomiting is severe, and accompanied by 
free salivation and muscular tremblings. After very large doses, vomit¬ 
ing does not occur, but a condition of intense restlessness is soon de¬ 
veloped, the animal often jumping in the air, running about the room, 
howling and champing constantly. The slightest noise or alarm throws 
him into violent excitement and terror; with pupils dilated, ears drawn 
stiffly back, he endeavors to get out of the apartment, and even to climb 
the wall. After still larger amounts (4 or 5 gr.), to this excitement is 
soon added failing muscular strength, and the hind legs are dragged 
behind the animal in his movements. The respiration is exceedingly 
hurried, and convulsions are suddenly developed. The paresis and con¬ 
vulsions increase, so that the animal lies upon his back, kicking wildly 
into the air, and finally he dies asphyxiated. Rabbits cannot vomit, 
but the general symptoms produced by the alkaloid in them and in cats 
are exactly parallel with those just described as occurring in the dog. 
Yery small doses (10 milligrammes, Harnack) suffice to kill the rabbit. 
On chickens and pigeons, according to C. David ( Gaz. Med., 1874, p. 
465), it acts very much as it does upon dogs; the stage of excitement 
is very marked. After death no distinctive lesions are to be found, 
unless; as Quehl (loc. cit., p. 19) believes, there is habitually an excessive 
hyperaemia of the pons Yarolii. 

To the therapeutist the chief interest in apomorphine is in connec¬ 
tion with its power of producing vomiting; but before taking this up 
I shall endeavor to portray what is known in regard to the physiologi¬ 
cal actions of the drug. 

Nervous System .—The action of apomorphine upon the cerebrum 
seems to be that of a primary stimulant delirifacient and final para¬ 
lyzant. The cause of the convulsions at present cannot be considered as 
made out.f According to Reichert’s experiments, both the sensory and 
motor nerves are first stimulated and afterwards paralyzed. In oppo¬ 
sition to the experiments of Quehl, Harnack found that the muscles in 
the frog around the place of injection soon lost their irritability, evi¬ 
dently from the poison reaching them in a concentrated form by imbi¬ 
bition. He also separated one hind leg of a frog from the rest of the 


* Consult E. Harnack, Arch. f. Exper. Path. u. Pharm., ii. 291; Max Quehl, Ueh&r der 
Physiol. Wirk. des Apomorphins, Inaug. Diss., Halle, 1872; I. B. V. Bourgeois, De l’Apomor¬ 
phine, Paris, 1872; E. Reichert, Phila. Med. Times, x. 110; G. Valentin, Arch. f. Exper. 
Path. u. Pharm., xi. 399. 

f The only one who has carefully studied them is Reichert, and his published account is 
self-contradictory. He reasons that the convulsions are chiefly spinal, and yet says that in 
mammals, after section of the spinal cord, except “ in very exceptional cases," they are con¬ 
fined to the anterior part of the body. 



662 


LOCAL REMEDIES. 


body, leaving only the nerve intact, and then poisoned with apomor- 
phine. After voluntary motion had ceased, the muscles of the intact 
leg were far less excitable than were those of the leg to which access 
of the poison had been prevented. These experiments have been con¬ 
firmed by Reichert, and there can be no doubt that apomorphine is a 
muscle-poison. 

Circulation .—The reports upon the action of this drug upon the 
circulation are somewhat discordant. Seibert (.London Med. Record , i. 
44), Max Quehl, and Bourgeois affirm that the blood-pressure is not 
affected even by toxic doses. Harnack, however, found after large 
doses in dogs a distinct fall of arterial pressure, and also that apomor¬ 
phine is a direct paralyzant of the cut-out frog’s heart. The latter fact 
has been confirmed by Reichert, who has also shown that the mamma¬ 
lian heart is similarly affected by the drug, and that finally this cardiac 
action causes a fall of the arterial pressure. Preceding the fall there 
was in Dr. Reichert’s experiments a distinct rise of arterial pressure, 
which was prevented by previous section of the cord, and was there¬ 
fore probably due to stimulation of the vaso-motor centres. Thera¬ 
peutic doses of the drug have no distinct action upon the force of the 
circulation. The pulse-rate is markedly increased by small and large 
doses of apomorphine, the maximum usually being reached about the 
time vomiting is fairly established ; subsequently, in poisoning, the pulse 
falls below normal. Reichert believes the rise to be due to stimula¬ 
tion of the accelerators, and the fall to the influence upon the.heart- 
muscle. 

Respiration .—Usually the respiration-rate is increased by decided or 
toxic doses; although the amount of increase varies greatly, it is often 
very large. Harnack says that after toxic doses the rate rises very 
much before the occurrence of convulsions, but Reichert has not been 
able to observe this. During the convulsive period the respirations 
become irregular and unequal, and they finally grow more and more 
shallow and infrequent, until death results from a paralysis of the 
respiratory centres. Both Harnack and Reichert have noted that in 
the rabbit previous section of the par vagum does not prevent, but 
rather increases, this acceleration, so that it would seem that apomor¬ 
phine stimulates the respiratory centres; but Reichert affirms that in 
the cat and dog no increase of the respiration-rate occurs under the 
action of the drug if the pneumogastrics have been cut. 

Temperature .—The action of apomorphine upon the temperature 
appears to be very trifling and inconstant. According to Ziolkowski 
(. Apomorphin , Inaug. Diss., Greifswald, 1872), the bodily heat usually 
falls after large doses from 0.1° to 0.5° C. Moerz noticed in one man 
that the temperature rose during the vomiting two-tenths of a degree; 
while Bourgeois affirms that in man the drug has no influence over the 
temperature, and Reichert has seen in animals a rise follow the hypo¬ 
dermic but not the intravenous injection of the alkaloid. 


EMETICS. 


663 


Emesis. —Dr. Gee ( St. Bartholomew's Uosp. Hep., vol. v. p. 215) was 
the first to announce that apomorphine is a certain and prompt emetic, 
producing but little nausea, and having the great advantage of acting 
in very small dose, a tenth of a grain being sufficient, when injected 
under the skin, to cause vomiting in ten minutes. His statements 
have been confirmed by very many observers, excepting that the dose 
employed by Gee is usually considered too large. Thus, Dr. Pierce 
(British Medical Journal , 1870, p. 274) employs one-fifteenth of a grain, 
and M. Bertrand ( Gaz. Med., 1874) has vomited with 0.06 grain. The 
time required for action depends largely upon the amount of the drug 
exhibited. After very small doses twenty minutes may elapse; and 
in Bourgeois’s experiments 0.45 grain produced violent vomiting in 
less than two minutes. After these large doses the emesis usually 
recurs once or twice at intervals of a quarter to half an hour.* The 
vomiting seems to be of centric origin, as Reichert has succeeded in 
producing it when the thoracic aorta was tied so as to prevent any of 
the poison from reaching the stomach. 

A knowledge of the effects of narcotics upon the action of apo¬ 
morphine is, of course, of great practical importance. There is as yet 
very little clinical evidence. A case of poisoning with bitter almonds 
has indeed been reported ( Schmidt's Jahrbucher, Bd. civ. p. 272), in 
which the injection of 0.013 grain of the alkaloid was followed by 
prompt emesis; but it is evident that no inference in regard to narcotic 
poisoning could be drawn from this. It is inconceivable that there 
should be any differences in the relation between apomorphine and nar¬ 
cotism in man and in animals, and the subject has been investigated, 
with mostly similar but insufficient results, upon animals by several 
observers.f In dogs chloral retards, or, if in sufficient dose, prevents, 
the emesis of apomorphine; during chloroform-sleep the alkaloid is 
affirmed by David and Dujardin-Beaumetz to be powerless; but MM. 
Coyne and Budin state that it will produce emesis even during pro¬ 
found anaesthesia if the dose be large enough; David found that in a 
dog three centigrammes of morphine prevented the occurrence of the 
vomiting. It is plain that these experiments prove no more than that 
narcotics influence the action of apomorphine as they do that of every 
other emetic; and the probabilities seem to be that the alkaloid pro¬ 
duces vomiting more surely than do our ordinarily used drugs. The 
emesis is probably the result of a stimulant action exerted upon the 
nerve-centres; and the fact that after toxic doses vomiting does not 
occur indicates that in such amounts the drug paralyzes these centres. 

Local Action. —Apomorphine is not an irritant, so that the hypo¬ 
dermic use of even concentrated solutions of it elicits in the lower 


* For the doses required to vomit various animals, see Gaz. Med,., 1874, p. 466. 
f E. Harnack ( loc. cit.); 0. C. David (Gaz. Med., 1874, p. 465); Dujardin-Beaumetz 
(Bull. Thirap., Oct. 1874). 



664 


LOCAL REMEDIES. 


animals no evidences of pain. In man the injections have sometimes 
caused intense pain, probably because they bad been originally im¬ 
properly prepared or bad undergone chemical change. 

Therapeutics. —There is now sufficient evidence to show that apo- 
morphine is a safe and reliable emetic, possessed of advantages which 
have already been sufficiently dwelt upon. It may be used whenever 
it is desired simply to empty the stomach. In narcotic poisoning there 
is no reason why it should not be given hypodermically while sulphate 
of zinc or some mechanical emetic is exhibited by the mouth. As an 
expectorant ,* apomorphine is employed with asserted great advantage 
in the suffocative catarrh of infants, when an emetic is required to get 
rid of the bronchial exudation. Under these circumstances it is said 
not only to act efficiently as an emetic, but also to render the mucus 
more copious and fluid. It is claimed that in the early stage of acute 
bronchitis it rapidly causes copious, loose secretion, and that in chronic 
bronchitis it is very useful when expectoration is scanty. 

Administration. —As an emetic, apomorphine has usually been ad¬ 
ministered hypodermically, in doses of one-tenth of a grain, repeated 
every ten minutes until some effect is induced; but it may be exhibited 
by the stomach in double the amount. In cases of severe poisoning, 
where time is of great moment, it may be well to give as much as one- 
fourth of a grain at a single injection. In feeble persons, however, 
caution must always be exercised in using it, as one-fifteenth of a grain 
has caused death in seven minutes in an adult, fifty-four years old, 
suffering from chronic bronchitis with marked emphysema {Med. Rec., 
1877, 664). Wertner gives the expectorant dose as 0.07 to 0.15 grain for 
children, or double the amount for the adult, repeated every two hours 
by the mouth. Care must be exercised in its use in children. In 
Yulpian’s clinic the dose is from 0.07 to 0.09 grain. Dr. Loeb ( Schmidt's 
Jahi'b., Bd. civ. p. 272) gave hypodermically 0.03 grain to an infant 
thirteen months old suffering from capillary bronchitis : the free vomit¬ 
ing which was induced left the infant much exhausted. In a very few 
cases apomorphine has failed to vomit, and even caused startling symp¬ 
toms : so that care should be exercised not to push the remedy too far. 
M. Carville affirms that three-tenths of a grain has caused a syncopal 
condition in an adult, and M. Prevost details a case {London Medical 
Record , 1875, p. 183) in which syncope and threatening collapse were 
apparently induced by a very small dose. In children especially must 
care be exercised, since, according to Harnack, the drug is very liable 
to produce collapse. The ordinary solutions of apomorphine undergo 
a rapid change, becoming green; and Dr. Loeb has reported a case in 
which very alarming symptoms followed the use of such a solution. 
M. Constantine Paul states that if glycerin be used as the sole men- 


* Dr. Jurasz (Centralbl.f. d. Mecl. Wise., 1874, 499); Dr. M. Wertner ( Wien. Med. Presse, 
1876, 269); Dr. Carl Beck ( Deutsch. Med. Wochenschr., 1881, 156). 



EMETICS. 


665 


struum the solution will keep three or four days. M. Carville ( Gaz. 
Hebdom ., 1874, p. 408) affirms that glucose acts well as a preservative, 
and it is also claimed that a few drops of muriatic acid will suffice. 

A very useful stimulating emetic is mustard flour , very prompt and 
even violent in its action. It acts as a mechanical emetio, and is to be 
used when it is desired simply to evacuate the stomach rapidly, and 
especially when there is torpor of the viscus. As it is generally to be 
had at once, it is especially useful in such emergencies as narcotic poison¬ 
ing. It has also been commended in nervous collapse , such as is seen in 
malarial pernicious chill. The dose is a heaped dessertspoonful in half 
a pint of water, repeated, if necessary, in ten minutes. As mustard is 
irritant to the stomach, if it fail to act it should not be repeated more 
than three or four times, even in narcotic poisoning. 

Squill (Scilla ) is sometimes used as a harsh, stimulating emetic. 

MINERAL EMETICS. 

Tartar emetic is the most depressing of all the substances here spoken 
of as emetics. It is rather slow in its action, but the vomiting which 
it causes is preceded and accompanied by intense nausea, and is ex¬ 
ceedingly violent and persistent. For these reasons, tartar emetic is 
rarely used simply to unload the stomach, except in the absence of 
more eligible substances. Its use in inflammatory diseases is discussed 
elsewhere. 

Sulphate of zinc is an excellent and prompt mechanical emetic, pro¬ 
ducing little or no irritation, and is to be preferred above all others 
when an emetic of such nature is needed. In narcotic poisoning it 
should be given in combination with ipecacuanha, and perhaps be 
preceded by mustard while it is being obtained from the apothecary. 
Thirty grains of it with fifty of ipecacuanha may be given as the first 
dose, and a mixture of fifteen grains of the former to thirty grains of 
the latter be administered every fifteen minutes until the desired effect 
is produced or one hundred grains of the zinc are taken. Beyond the 
latter amount it would be hardly safe to go, for fear of gastro-enteritis. 

Sulphate of copper resembles the corresponding zinc salt as an emetic, 
but is more severe and irritating, and more capable of causing gastro¬ 
enteritis. The full dose in narcotic poisoning is from five to ten grains, 
which should not be repeated more than once. 

Powdered alum is a mechanical emetic which has been especially 
recommended in membranous croup, on account of its being believed to 
act beneficially upon diseased surfaces in its passage up and down the 
throat. A heaped teaspoonful of it may be given in molasses or syrup. 
In my experience alum has proved an unreliable emetic. 


FAMILY in.— CATHARTICS. 


Purgatives, or cathartics, are those drugs which are employed in 
medicine to produce purgation, or catharsis, by increasing either the 
intestinal secretions or the peristaltic movements. 

M. Thiry ( Sitzungsb . der k. k. Acad. d. TPitss., Bd. 1.) experimented upon 
the subject of catharsis by drawing out a knuckle of intestine through 
a wound in the linea alba, cutting it free from the remainder of the gut 
without injuring its nerves or blood-vessels, sewing together the distal 
and proximal ends of the main portions of the intestines so as to re¬ 
form a continuous tube, and then, after closing up one end of the 
knuckle, forcing the other into the wound so as to make an intestinal 
cul-de-sac which could be studied through a fistulous opening. In dogs 
which had recovered after this operation, Thiry found that large doses 
of sulphate of magnesium, of senna, or of croton oil failed alike to 
increase the secretion of the separated piece of intestine, although they 
induced violent purging; further, that neither concentrated solutions 
of Epsom salt nor infusion of senna, even though kept in the cul-de-sac 
for some time, were able to increase its secretion by exosmose. More 
recently, Dr. S. Eadziejewski has made an elaborate investigation of 
the subject ( Reichert's Archiv, 1870, p. 37). As the result of a number 
of very careful analyses, he asserts that there is nothing to be found 
in the stools produced by sulphate of magnesium, calomel, castor 
oil, croton oil, senna, or gamboge, to indicate that they are anything 
besides the ordinary contents of the upper and lower bowels. Dr. 
Eadziejewski confirms the fact observed by C. Schmidt, that the stools 
of purgatives contain a great deal of soda, but denies that this proves 
that they are transudations, asserting that the alkaline salts are 
derived simply from the pancreatic fluid. Dr. Eadziejewski also cor¬ 
roborates the confirmation by Asp ( Ludwig's Arbeiten , 1868) of the dis¬ 
covery of Moreau,* that division of the intestinal nerves is followed by 
free serous exudation into the gut, but denies that purgatives aot by 
paralyzing the vaso-motor nerves, because croton oil injected into a 
loop of intestine which had been separated by two ligatures from the 
remainder of the gut caused both vomiting and purging. As no emul¬ 
sifying substance was contained in the intestine, he declares that no 
absorption could have occurred, and that consequently the general 


* Comptes-Hendm, t. lxvi., 1868; also Asp, Ludwig’s Arbeiten, 1868. 




CATHARTICS. 


667 


intestinal disturbance was simply due to increased peristaltic action, 
caused by the internal local irritation of the oil propagated along 
the intestines. The experiments of Thiry have also been repeated by 
Radziejewski with croton oil and with sulphate of magnesium, as well 
as by Schitf (. Nuove Richerche sul Potere digerente, H. Morgagni, 1867) 
with aloes, jalap, and sulphate of sodium. In all cases the results were 
the same as those already noted as obtained by Thiry. Carrying his 
investigations still further, Radziejewski, by forming intestinal fistulee 
at such positions as would enable him to study the rate of passage of 
the intestinal contents, found that after a dog is fed upon flesh the 
small intestine empties the partially-digested food into the colon so 
rapidly and in such quantity as to constitute, so to speak, a normal 
diarrhoea, and that the long delay in the exit and the hardening of the 
faeces occur in the large intestine. The liquid which passed into the 
ascending colon agreed in all its characteristics with the stools of pur¬ 
gation. Dr. Radziejewski also claims to have established by direct 
experimentation that the peristaltic movements of the small intestine 
are atfected very decidedly by drastics, and to some degree by Epsom 
salt, and that in all cases the large intestine is still more intensely 
acted upon. Although these experiments are very interesting, it can¬ 
not be allowed that they prove what is claimed for them, namely, that 
purgatives cause no increase of intestinal secretion, but only of peri¬ 
staltic action. So much violence to natural conditions is done in the 
experiments after the method of Thiry that they seem to have very 
little weight. The assumption of Radziejewski, that croton oil con¬ 
fined in a loop of intestine is not absorbed, is a pure assumption, and 
his experiment does not warrant the conclusions drawn from it. 

The other facts brought forward seem to prove only that increased 
peristalsis, especially of the large bowel, plays a more important role 
in the indication of diarrhoea than has been assigned to it. 

Leaving out of sight for the moment all clinical evidence, the fact 
that previous section of the par vagum prevents the action of purga¬ 
tives* is opposed to the German theory, since it is almost certain that 
the division of the nerves of the neck does not arrest peristaltic move¬ 
ments. Further, Armand Moreau (Archives Gen., 6e ser., t. xvi. p. 234) 
has found that a solution of Epsom salt placed in a knuckle of intes¬ 
tine isolated by means of two ligatures does cause a serous exudation 
into it. and in repeating M. Thiry’s experiments ( Gaz. Med., 1871) he 
has obtained opposite results. His experiments indicate three possible 
sources of fallacy in the work of the previous investigators: first, if 
the Ej)som salt be not kept in the intestine for a sufficient length of 
time (some hours), no traAsudation occurs; second, in some cases the 
inner end of the isolated piece of intestine fails to adhere, so that the 
opening is not obliterated, and the matters injected into the arrested 


* See paper by the author, American Journal of the Medical Sciences, vol. lx., 1870. 



668 


LOCAL REMEDIES. 


cul-de-sac really pass into the peritoneal cavity; third, atrophy of the 
mucous membrane and glandular apparatus of the cul-de-sac often fol¬ 
lows almost at once upon the operation, and of course necessitates a 
negative result in the subsequent experiments. Dr. Lauder Brunton, 
in a communication to the Medical Society of London, states that he 
has repeated Moreau’s experiments, and found that sulphate of mag¬ 
nesium injected into the intestine of a cat caused about two-thirds 
of a drachm of fluid to be secreted in four hours by each inch of the 
bowel operated on, although the proportion of sulphate was only one 
grain to an inch {Med. Press and Circular , Dec. 31, 1873). In further 
experiments by Dr. Brunton, gamboge, elaterium, and croton oil gave 
results similar to those of the Epsom salt ( Practitioner , May, 1875). 
M. Vulpian has also repeated the experiments of Moreau, and found 
that both sulphate of magnesium and jalap provoke a “ true intestinal 
catarrh,” the vegetable cathartic at the same time increasing the peri¬ 
staltic action, but the saline having no such effect ( Gaz. Med., 1873, 
p. 300). M. Legros ( Ibid .), and M. Yan Braam Houckgeest ( Pfluger's 
Archiv, 1872, p. 266), have experimentally determined that salines do 
not increase the activity of the peristaltic movements.* 


* Dr. Matthew Hay (Journ. Anat. Physiol., xvi., xvii.) has exhaustively investigated the 
action of saline cathartics. Space is wanting in which to discuss his article in detail, but the 
following are his results as formulated by himself: 

1. A saline purgative always excites more or less secretion from the alimentary canal, 
depending on the amount of the salt and the strength of its solution, and varying with the 
nature of the salt. 

2. The excito-secretory action of the salt is probably due to the bitterness as well as to 
the irritant and specific properties of the salt, and not to osmosis. 

3. The low diffusibility of the salt impedes the absorption of the secreted fluid. 

4. Between stimulated secretion on the one hand, and impeded absorption on the other, 
there is an accumulation of fluid in the canal. 

5. The accumulated fluid, partly from ordinary dynamical laws, partly from a gentle 
stimulation of the peristaltic movements excited by distention, reaches the rectum and pro¬ 
duces purgation. 

6. Purgation will not ensue if water be withheld from the diet for one or two days pre¬ 
vious to the administration of the salt in a concentrated form. 

7. The absence of purgation is not due to the want of water in the alimentary canal, but 
to its deficiency in the blood. 

8. Under ordinary conditions, with an unrestricted supply of water, the maximal amount 
of fluid accumulated within the canal corresponds very nearly to the quantity of water re¬ 
quired to form a five- or six-per-cent, solution of the amount of salt administered. ■ 

9. If, therefore, a solution of this strength be given, it does not increase in bulk. 

10. If a solution of greater strength be administered, it rapidly increases in volume until 
the maximum is attained. This it accomplishes in the case of a twenty-per-cent, solution in 
from one to one and a half hours. 

11. After the maximum has been reached, the fluid begins gradually and slowly to di¬ 
minish in quantity. 

12. Cfeteris paribus, the weaker, or, in other words, the more voluminous, the solution of 
the salt administered is, the more quickly is the maximum within the canal reached; and 
accordingly purgation follows with greater rapidity. 

13. Unless the solution of the salt is more concentrated than ten per cent., it excites little 
or no secretion in the stomach. 



CATHARTICS. 


669 


The experimental evidence bearing upon the question under discus¬ 
sion is, so far as I know, all included in the foregoing summary: it is 
very far from demonstrating that increased peristalsis, and not increased 
secretion, is the cause of the watery stools produced by purgatives. 
The evidence, both experimental and clinical, is indeed overwhelmingly 
in favor of increased secretion. The facts proved by clinical observa- 

14. The salt is absorbed with extreme slowness by the stomach of the cat. 

15. The salt excites an active secretion in the intestines, and probably for the most part 
in the small intestine, all portions of this viscus being capable of yielding the secretion in 
almost equal quantities. 

16. The bile and pancreatic juice participate very little in the secretion. 

17. The secretion is probably a true auccua entericus, resembling the secretion obtained by 
Moreau after division of the mesenteric nerves. 

18. The secretion is promoted by local irritation of the intestine, as by ligatures, but only 
in the immediate vicinity of the irritation. 

19. Absorption by the intestine generally is rellexly stimulated by such irritation (the 
effect of numerous ligatures applied at points remote from the seat of the injected salt being 
to diminish the amount of purgative fluid by accelerated absorption). 

20. If the salt solution be injected directly into the small intestine, the stronger within 
certain limits the solution is, the greater will be the accumulation of fluid within the in¬ 
testine. 

21. This difference is not observed when the salt is administered per oa, as the strong 
solution becomes diluted in the stomach and duodenum before passing into the intestine 
generally. 

22. The difference is due to the local action of the salt on the mucous membrane, and 
probably more to an impeded absorption than to a stimulated secretion. 

23. When the salt is administered in the usual manner, it appears, in the case of the sul¬ 
phate of magnesium, and sulphate of sodium, to become split up in the small intestine, the 
acid being more rapidly absorbed than the base. 

24. A portion of the absorbed acid shortly afterwards returns to the intestines. 

25. After the maximum of excretion of the acid has been reached, the salt begins very 
slowly and gradually to disappear by absorption, which is checked only by the occurrence of 
purgation. 

26. During the alternations of absorption and secretion of the acid, it is the salt left 
within the intestine which excites secretion, the absorbed and excreted acid exerting no such 
action while in the blood, or during the process of its excretion, as Headland believed. 

27. The salt does not purge when injected into the blood, and excites no intestinal secre¬ 
tion. 

28. Nor does it purge, when injected subcutaneously, unless in virtue of its causing local 
irritation of the abdominal subcutaneous tissue, which acts reflexly on the intestines, dilating 
their blood-vessels, and perhaps stimulating their muscular movements. 

29. The sulphate of sodium exhibits no poisonous action when injected into the circulation. 

30. The sulphate of magnesium is, on the other hand, powerfully toxic when so injected, 
paralyzing first the respiration and afterwards the heart, and abolishing sensation or para¬ 
lyzing the sensory-motor reflex centres. 

31. Both salts, when .administered in the usual manner, produce a gradual but well- 
marked increase in the tension of the pulse. 

32. According as the salt-solution within the intestine increases in amount, there occurs 
a corresponding diminution of the fluids of the blood. 

33. The blood recoups itself in a short time by absorbing from the tissues a nearly equal 
quantity of their fluids. 

34. The salt, after some hours, causes diuresis, and with it a second concentration of the 
blood, which continues so long as the diuresis is active. 

35. As the intestinal secretion excited by the salt contains a very small proportion of 
organic matter as compared with the inorganic matter, the purgative removes more of the 




670 


LOCAL REMEDIES. 


tions and by experiment—that purgatives increase greatly the secre¬ 
tion in an isolated knuckle of intestine, that various purgatives act 
when taken into the blood, and that in these cases elimination by the 
bowels occurs; that at least some purgatives (Headland, Action of Medi¬ 
cines , London, 1867, p. 443), when given by the mouth, are absorbed, 
disappearing from the alimentary canal and reappearing when purga¬ 
tion occurs; that the stools induced by overdoses of various drastics, 
as elaterium, are so enormous as to cause the profoundest depression, 
and even choleraic collapse, in a very few hours; that the discharges 
caused by hydragogues contain a large percentage of soda, the alkali of 
the serum; that the relief obtained in portal congestion by the depletion 
of salines is very marked—are, when viewed together, to my mind, in¬ 
compatible with any other belief than that purgatives cause increased 
secretion, as well as, in many cases, increased peristalsis, in the alimen¬ 
tary canal. 

The question of the action of drugs upon the flow of bile is a very 
important one, the evidence concerning which is best considered under 
two headings: first, the experimental; second, the clinical. 

The experiments upon this subject which have attracted most atten¬ 
tion are those of Dr. Scott, and of the Edinburgh committee, of which 
Professor Bennett was chairman and Drs. Rutherford and Gamgee the 
workers. The method employed both by Dr. Scott and by the Edin¬ 
burgh committee was to make biliary fistulse in dogs in the usual phys¬ 
iological method, and, after recovery from the operation had taken 
place and the bile regularly escaped by the external orifice, to admin¬ 
ister the drugs, especially calomel and podophyllin, and study the 
effects upon the excretion of bile. Of the accuracy of their experi¬ 
ments I do not think there can be any reasonable doubt. I believe 
they prove that in dogs with biliary fistulse mercury has no effect upon 
the flow of bile unless given in such quantities as to deteriorate the 
general health, when it diminishes the biliary secretion. The result 
does not, however, warrant the further conclusion that mercury does 
not increase the flow of bile in healthy dogs. The animals were in 
such an unnatural condition that, in spite of the daily ingestion of 
much more than the normal amount of food, they progressively ema¬ 
ciated, and finally died apparently of inanition: moreover, the inner¬ 
vation and probably also the blood-supply of the liver was very 
much interfered with. Under these circumstances it is clearly con¬ 
ceivable that the mercurial or other purgative might in the uninjured 

latter than of the former from the blood. In certain cases a large quantity of the salts of the 
blood is thus evacuated. 

36. The amount of the normal constituents of the urine is not affected by the salt. 

37. After the administration of sulphate of magnesium much more of the acid than of the 
base is excreted in the urine. 

38. The salt has no specific action in lowering the internal temperature of the body, or 
has it only to a very small extent. 

39. It reduces, however, the absolute amount of heat in the body. 



CATHARTICS. 


671 


dog affect the biliary secretion, and yet fail to do so in the experiment, 
hindered by some obscure yet efficient cause. Dr. A. Rdhrig experi¬ 
mented ( Strieker's Medicin. Jahrbucher, 1873) by a method which 
simulated more closely the natural conditions; although even the re¬ 
sults which he thus obtained do not seem to me conclusive. In cura- 
rized dogs in which life was maintained by artificial respiration, he 
placed a glass tube in the gall-duct so that the bile could escape only 
through it. Under these circumstances, of course, after a time secretion 
ceased; and Dr. Rohrig experimented not only on the effect of reme¬ 
dies upon the secretion while it was naturally going on, but also on their 
power of re-establishing it. He found that large doses of croton oil 
(eighteen drops) thrown into the duodenum caused an immediate very 
great increase, or a re-establishment, of the secretion. After the oil, the 
vegetable cathartics were most active, decreasing in power in the fol¬ 
lowing order : colocynth, jalap and aloes, rhubarb and senna. Castor 
oil had very little influence, as had also the bitter salts. Calomel, even 
in large doses (twenty grains), very rarely re-established the secretion, 
but its power of increasing and maintaining it beyond the natural time 
for cessation was very marked. 

Professor W. Rutherford, in an extended and laborious research, 
used the method of Rohrig with some improvements ( Trans. Roy. Soc. 
Edinb ., xxix.). The drug, mixed with bile to facilitate absorption, was 
injected directly into the duodenum by means of a hypodermic syringe. 
The results obtained may be briefly summarized as follows: 

Croton Oil in enormous doses neither purged nor affected the biliary 
secretion. 

Podophyllin very greatly increased biliary secretion, especially when 
in such small doses that it did not purge severely. 

Aloes very greatly increased biliary secretion, the doses used not 
purging greatly. 

Rhubarb, Colchicum, Iridin, Colocynth, Jalap, Sulphate of Sodium, 
Phosphate of Sodium , Rochelle Salt, very greatly increased biliary secre¬ 
tion, at the same time purging. 

Senna, Taraxacum, Scammony, Gamboge, Castor Oil, Sulphate of 
Magnesium, Chloride of Ammonium, acted very feebly, if at all, upon 
the liver. 

Leptandrin, Chloride of Sodium, Bicarbonate of Potassium, had some, 
but not a powerful, effect on the liver. 

Euonymin, Sanguinarine, Ipecacuanha, exerted a very powerful in¬ 
fluence on the secretion of bile, and did not purge. 

Calomel had no effect on the biliary secretion, but when to it a 
minute proportion of corrosive sublimate was added the effect was 
very marked; Corrosive Sublimate acted as a very powerful biliary 
stimulant. 

There is one objection to the experiments of Rutherford and Vignal, 
entirely independent of the method employed; i.e., there were rarely more 


672 


LOCAL REMEDIES. 


than two experiments with any one substance, and in several instances 
two experiments gave antagonistic results. It is very possible, indeed 
probable, that if a number of experiments had been made with each 
drug, the variation in results would have been much greater. 

Dr. Hess ( Deutsch. Arch, fur Klin. Med., Bd. xl.) has made a series 
of experiments in regard to.the effects of purgatives upon peristalsis 
by introducing into the duodenum, through a gastric fistula, a disten¬ 
sible ball, which can be blown up by the long tube attached to it so 
as to fill the intestine, and noticing the rate at which the ball moves 
under the influence of a peristaltic movement. With this ap}:)aratus he 
studied the action of sulphate of sodium, castor oil, senna, and croton 
oil. The least effect upon peristalsis was produced by the senna, the 
most by croton oil. Dr. Hess also states that when, by the blowing up 
of the ball in the intestine, sulphate of sodium, castor oil, calomel, senna 
leaves, croton oil, and colocynth were prevented from passing into the 
lower intestine, they failed to purge, although when introduced below 
the obstructing ball by a narrow tube running through it they at once 
caused diarrhoea. These experiments, if confirmed, would prove that 
the purgatives mentioned must come in direct contact with the lower 
part of the small intestine to produce liquid stools. 

What is to be drawn from these various facts ? Evidently, I think, 
but one conclusion,—that the experimental evidence at present does 
not warrant positive deductions as to the effect of purgatives upon the 
biliary secretion of healthy dogs. The canine diet and digestion are 
so different from the human that it is to be expected that medicines 
acting upon the digestive apparatus will influence dogs differently 
from man: thus, I have given doses of elaterium that would have 
killed a man to some of the carnivora without causing the slightest 
purging. In view of these facts, the only fairly deducible conclusion 
in regard to the experimental evidence that has been brought forward 
is, that it must be received with the greatest reserve or be entirely laid 
aside when we desire to study the question as to the cholagogue action 
of remedies upon man, and that our conclusions are most safely based 
upon clinical evidence. 

In regard to the drastics, there can be little doubt that almost any 
irritant purgative will to a greater or less extent increase the escape 
of bile, probably both by increasing its flow into the duodenum and by 
sweeping it out of the small intestine before absorption can take place. 
There are, however, two actively purgative substances for which it is 
especially claimed that they are cholagogues,—namely, calomel and 
podophyllin. The discussion of the action of these will be found under 
their respective headings. 

Dr. Hugo Heinrichsen has found ( Schmidt's Jahrb., Bd. ccii. p. 214) 
that the excretion of urine is diminished by purgatives,—very much 
so by Glauber’s and Epsom salts, slightly by castor oil and compound 
liquorice powder. The solids of the urine are not sensibly affected by 


CATHARTICS. 


673 


the vegetable cathartics. Under the influence of the salines the solids 
of the urine are increased. Glauber’s salt is said to be partially con¬ 
verted into an allvaline carbonate, and to give thereby an alkaline reac¬ 
tion to the urine. 

Various divisions of purgative medicines have been proposed by 
different authors; but probably the most convenient arrangement is 
as follows: 

1. Laxatives. —Medicines which simply unload the bowels, and are 
not able to cause active purgation, even when given in very large doses. 

2. Purges. —Medicines which purge actively, but are not capable of 
acting as poisons, even in very large amount. 

3. Hydragogues (including the Salines ), which produce very large 
watery stools without much irritation. In overdoses, medicines of this 
class assume some of the characters of those of the next. 

4. Drastics , which cause great irritation of the alimentary mucous 
membrane, and in overdoses are violent poisons. 

It must be borne in mind that this classification is somewhat arti¬ 
ficial ; that the effects of the remedies depend much upon the doses in 
which they are administered, so that in sufficiently minute quantity a 
drastic may act as a laxative; and that the dividing-lines between the 
groups are not very distinct. 

Enemata. —When it is desired simply to unload the lower bowels, 
the object can often be advantageously attained by injecting various 
materials into the rectum, so as by mechanical distention, or by irri¬ 
tating the mucous membrane, to stimulate the peristaltic action. The 
simplest, least irritant, and least active enema is one of cold water. In 
cases of habitual constipation, especially when complicated with piles, 
the injection of a pint of cold water at a fixed hour daily often acts 
most kindly. The ordinary opening injection consists of a pint of water, 
and a tablespoonful, each, of salt, molasses, and soft soap; castor oil is 
often added to it, and, if it be desired to make it very active, a tea¬ 
spoonful of oil of turpentine. 

Forced enemata. —The forced injection of large quantities of water 
for the relief of certain diseased conditions has long been employed in 
an irregular way; but the practice has become more common since 
Gustav Simon has proved the possibility of readily filling the large and 
even the small intestine, by forcing water into the rectum and through 
two patients suffering from intestinal fistula, the opening leading in the 
one case into the large intestine about the junction of the caecum and 
the ascending colon, in the other probably into the small intestine 
(.Archiv f. Klin. Chir., xv.). Mosler has experimented on a patient 
in whom a finger introduced through the fistulous opening could feel 
the ileo-caecal valve. Using a method to be shortly described, he found 
that in two minutes from the time water first entered the rectum it 
commenced to stream from the orifice, having traversed the whole 
length of the large intestine ( Berlin. IClin. Wochenschr., No. 45, 1873). 

43 


674 


LOCAL REMEDIES. 


Forced enemata are of especial value in intussusception , in which 
disease they have not rarely relieved the symptoms at once by me¬ 
chanically distending and unfolding the invaginated gut. Dr. Mosler 
also commends them in hernia , and has employed them as anthelmintics. 
As such they are, of course, especially useful against the oxyuris ver- 
micularis, which often inhabits the whole of the large intestine; but 
Dr. Mosler succeeded with them in removing a large tape-worm , prob¬ 
ably from the colon. Especially in the case of the seat-worm , the ver¬ 
mifugal enemata should be medicated; and probably the safest and 
most efficient substance for this purpose is quassia. Dr. Mosler used a 
tablespoonful of chlorine-water to every pint and a half of injection. 
In various catarrhal and other diseases of the large intestine, Mosler 
commends these large enemata as a means of cleansing the gut, re¬ 
moving acrid secretions or foreign matters, and applying local treat¬ 
ment. A. Bohrig ( Experim. Untersuch. u. d. Physiol, der Gallenabson- 
derung, Vienna, 1873) having found that intestinal injections of water 
have a veiy great influence over the secretion of bile, Dr. Mosler has 
been led to try forced enemata in catarrhal and other jaundices , with 
asserted good results. I have myself used in chronic dysentery forced 
enemata of a drachm of nitrate of silver dissolved in a half-gallon of 
water, with excellent results; and the method is undoubtedly applicable 
to the treatment of acute colitis ,—cold, chloral, sublimate of bismuth, 
or other agencies or remedies being used pro re nata. 

In administering these large injections a syringe should never be 
used. The apparatus to be provided consists of a rectal tube of hard 
rubber, with a conical point, below which are several good-sized open¬ 
ings ; an india-rubber tube, two feet and a half long, fitted to the rectal 
tube; and a funnel. The patient should lie upon his back, with the hips 
elevated. The tube being introduced into the rectum, the free end 
with the funnel is raised vertically, and water poured into it. When 
it is desired to force fluid into the small intestine, much depends upon 
the introduction being performed slowly, and the patient should be 
placed upon his knees and shoulders, so that the pelvis may be much 
higher than the shoulder. It is essential that the tube be fitted with 
a cock, or be pinched, so as to regulate the passage of the liquid. In 
this way from five to nine pints are readily injected. 

The indications to fulfil which cathartics are used are as follows: 

1. To unload the bowels. —It is not necessary, in a work like the 
present, to say anything about the evil results of retained fecal matter, 
but only to point out the methods of relief. Before this can be done 
to advantage, however, a summary of the causes of constipation is re¬ 
quired. Constipation may be well divided into acute and chronic. 
Acute or temporary constipation is that which occurs under special, 
transient circumstances, as in convalescence from acute disease, and in 
pregnancy. It is to be relieved by the use of laxative articles of diet, 
and, this not sufficing, by laxatives or purgative medicines. It should 


CATHARTICS. 


675 


never be forgotten that acute constipation is sometimes due to organic 
affections of the alimentary canal, such as enteritis or intussusception, 
or is caused by mechanical obstacles, such as a hard foreign body or an 
enormous gall-stone. It is evident that such cases are not simple con¬ 
stipation,—that the treatment required is essentially different from that 
of the latter affection, and is various according to the lesion. For the 
diagnosis and treatment of these diseases the reader is referred to 
works on the practice of medicine. Chronic constipation may be due to 
sedentary habits of life; to habitual overwork, especially of the ner¬ 
vous system; to a deficiency of intestinal secretion and of peristalsis, 
apparently natural to the individual and without obvious cause; to 
long-continued voluntary habit of restraining the desire to go to stool; 
to lead or other forms of poisoning; and to diseases of the nervous 
system producing a paralytic state of the intestinal muscular fibres. 
It is evident that in the treatment of these various forms of constipa¬ 
tion due regard must be paid to the cause, which should always, if 
possible, be removed. There are also certain cardinal principles which 
apply to the treatment of all forms of chronic constipation. They are 
as follows: 

1. A voluntary effort at defecation is to be daily made at a fixed 
hour, whether the desire exists or not. 

2. Medicines are to be avoided as far as possible, a sustained effort 
being made to regulate the bowels by means of diet. 

3. In very many cases the daily use of enemata of cold water, with 
attention to diet, suffices to attain the desired result. 

4. If medicines become necessary, as small an amount as will suffice, 
and the mildest drugs, are to be used. Purgatives or laxatives are at 
best merely temporary devices, and if abused in costiveness increase 
the trouble. So far as can be, the attempt should be to produce a per¬ 
manent impression, an alteration of the intestinal glandular action or 
peristalsis. Thus, when atony of the muscular coat exists, strychnine, 
or, according to recent experiments and clinical observations, Calabar 
bean, may be employed; if the hepatic or other glands are habitually 
torpid, nitro-muriatic acid may be administered. 

When constipation is attended with low spirits and a coated tongue, 
it is almost always due to a deficiency of secretion, and may be looked 
upon as a form of dyspepsia: in such cases nitro-muriatic acid is espe¬ 
cially valuable, but sometimes a mild mercurial course seems almost 
imperative. 

A second use of cathartics under the present indication is to remove 
offending materials, as indigestible or irritant food, foreign bodies, acrid 
discharges, etc. For these purposes a brisk, quickly-acting purgative 
is generally best. 

2. To deplete .—On account of the large serous flow which they pro¬ 
duce, the hydragogue cathartics when freely exhibited cause a very 
decided general depletion. 


676 


LOCAL REMEDIES. 


Local depletion by means of cathartics is called for in congestion of 
the portal circulation , as well as in dysentery and other acute intestinal 
inflammations. Under the first of these conditions may, we think, he 
included without violence cases of the so-called “ torpidity of the liver,” 
which will be discussed in the article upon calomel. In acute intestinal 
inflammations the salines are to be preferred when depletion is desired, 
as they produce very large serous discharges and are not at all irritant. 

3. To promote absorption. —By emptying the blood-vessels the ca¬ 
thartics favor the absorption of the exuded fluid in general dropsy. 
For this purpose the hydragogues, and especially elaterium, are the 
best purgatives. The production of catharsis is the surest method of 
relief in general dropsy , also in ascites ; in other forms of local effusion 
its effects are less marked. As, however, purgation is the most ex¬ 
hausting of all the plans employed for the cure of dropsy, due regard 
must always be had to the strength of the patient. It is frequently 
necessary actively to support or even to stimulate while it is being 
carried out. 

4. To revulse. —The long tract of the alimentary canal affords a 
great extent of surface upon which to practise revulsion in certain 
brain-diseases, as in mania and rheumatic or gouty irritation of the 
cerebrum. In hypercemia of the brain, purgatives do good by depleting 
as well as by acting as revulsives. The drastics should be preferred. 

5. To eliminate. —It cannot be doubted that the use of purgatives in 
such diseases as fevers and cholera, with the idea of eliminating some 
materies morbi , rests simply upon a crude, unproved, and probably false 
pathology. In rheumatic disease and in gout it is more probable that 
they do good in this way, although it is by no means certain that the 
advantage derived from their use is not simply due to depletion. In 
cases of retained renal secretion, the evidence is very decided that they 
do aid in separating the products of retrograde metamorphosis from 
the blood. 

6. To influence the pelvic circulation. —The only purgative used for 
this purpose is aloes, in the article upon which all that is necessary 
will be said upon the subject. 

LAXATIVES. 

As has been already stated, constipation should always, when pos¬ 
sible, be overcome by laxative food. There are two qualities by virtue 
of which food is laxative. Chief of these is bulk. All aliment which 
contains a large amount of innutritious material affords a large re¬ 
siduum, which, by distending the intestine, stimulates peristalsis. Con¬ 
trariwise, articles of diet which are highly nutritious and afford but 
little residuum are constipating. This holds good, more or less strictly, 
among the lower animals. Thus, the flesh-eating carnivora are habitu¬ 
ally constipated, the grass-eating herbivora very generally lax. Owing 
to its containing so little of the innutritious portion of the grain, the 


CATHARTICS. 


677 


finest white flour favors a costive habit, while the “ cracked wheat,” in 
which the whole grain is eaten, is laxative,—as to a still greater degree 
is bran, which is composed almost wholly of the husk of the wheat, 
the least nutritious portion of it, and therefore leaves a large residuum 
after digestion. Cracked wheat is boiled into a sort of jelly-like mass, 
and eaten with cream and sugar, while bran is taken in the form of 
bran bread, bran crackers, or bran mush. Unbolted flour , containing 
the whole of the grain, is about equal to cracked wheat, and is often 
made into bread. Indian meal , in the form of cakes or of mush, is 
highly nutritious, and somewhat laxative; oatmeal is decidedly laxa¬ 
tive, scarcely so much so as bran, but much more nutritious. When it 
agrees with the stomach, and is easily digested, it is probably the best 
of all these laxative articles of food. As the oats produced in southern 
climates are very inferior, care should be taken to procure oatmeal 
manufactured from Northern grain. It should be thoroughly cooked, 
and is best eaten in the form of a thick porridge. In dyspepsia all of 
these articles sometimes disagree with the stomach and cannot be used. 

Some dietary articles seemingly possess dynamic laxative powers,— 
i.e., they exert a direct action which is not mechanical, but is similar 
to, although far less active than, that of the true purgatives. They 
intensify the intestinal action. Chief among substances of this class 
are molasses (Syrupus Fuscus , U.S.), and its congener, brown sugar; 
white sugar (Saccharum , U.S.) probably does not share these laxative 
powers; sugar of milk (Saccharum Lactis, U.S.) is probably also nearly 
inert. Of course, great care is usually necessary in taking advantage 
of the laxative virtue of molasses, on account of the danger of pro¬ 
ducing fermentation and acidity in the prirase vhe. An obvious de¬ 
duction, however, is to encourage the use of brown instead of white 
sugar in those of constipated habit. 

There are certain foods which combine the two methods of action 
spoken of. Chief among these are the fresh acidulous fruits—such as 
apples, pears, etc.—and the dried fruits. Of the latter, the fig (Ficus, 
U.S.) is one of the most palatable, and, owing probably to the great 
number of small seeds which it contains, is the most efficient. Prunes 
are nearly as agreeable as figs. To a limited extent the finest varieties 
of them may be eaten raw ; but they are especially to be recommended 
stewed. When it is necessary, a pinch of senna-leaves may be cooked 
with them, and, if it be not made too large, increases the activity of 
the dessert without affecting its flavor. 

Among constipating articles of diet, it is only necessary to call 
attention to milk as one of the most decided of the class. 

The laxative remedies of the U.S. Pharmacopoeia are as follows: 

T AM ARINDUS—TAMARINDS. U.S. 

The preserved pulp of the fruit of Tamarindus Indica, a large tree, 
native of the East and West Indies. The fruit is a broad, compressed 


678 


LOCAL REMEDIES. 


pod, usually from four to six inches long, somewhat curved, with an ex¬ 
terior brown hard rind. It contains seeds enclosed in cells formed of a 
tough membrane, between which and the rind is an acid pulp, the medi¬ 
cinal part of the fruit. Tamarinds are preserved for market by stripping 
off the outer rind, packing the inner portion in layers, and pouring on 
boiling syrup. In the market they are offered as adhesive masses com¬ 
posed of pulp, membranes, strings, and seeds, and having a sweet acidu¬ 
lous taste. They contain a good deal of citric acid, much less tartaric 
acid, and a little malic acid. They are used chiefly in making refrigerant 
acidulous drinks for fever, and in convalescence as a laxative article 
of diet, half an ounce to an ounce or more being eaten like preserves. 
They enter into the officinal confection of senna. 

MANNA—MANNA. U.S. 

An exudation of the European ash, Fraxinus Ornus, chiefly pro¬ 
duced in Sicily and Calabria. There are three varieties of it. The 
best, flake manna , occurs in unequal, rough, stalactite-like pieces with a 
crystalline or granular fracture, and is obtained in the hottest and dry- 
est weather in July and August. The next quality, manna in sorts, 
consists of pieces of flake manna, mixed with a soft brownish matter: 
it is obtained in September. Fat manna, a soft viscous mass, which 
exudes during the wet weather in the latter part of October and in 
November, is the least valuable variety. Manna has a slight odor, a 
sweet, mawkish taste, and should contain from forty to eighty per 
cent, of the saccharine, active, crystalline principle Mannite, which 
differs from ordinary sugar in not containing equal parts of hydrogen 
and oxygen, and is therefore not readily convertible into grape sugar 
or its derivative, alcohol. 

Therapeutics. —Manna is a gentle laxative in large doses, some¬ 
times causing flatulence and pain. It is rarely used by itself, but is 
added to infusions of more powerful purgatives, to cover their taste 
and aid in their effects. The laxative dose for an adult is half an ounce 
to two ounces; for a child, one to four drachms in an aromatic infusion. 

Cassia Fistula. U.S .—Purging Cassia is the pulp of a hard, black¬ 
ish, cylindrical pod from one to two feet in length and about an inch 
in diameter, having on one side a single and on the other a double 
dark band, running the whole length of the pod, and marking the 
positions where its valves are united. The pods are produced by a 
large tree, Cassia Fistula, a native of Egypt and India. The dark, 
sweetish, acidulous, officinal pulp may be used as a laxative in doses 
of half an ounce, but is apt to cause griping. It enters into the offi¬ 
cinal confection of senna. 

Frangula. U.S.—The bark of Bhamnus Frangula, one of the 
buckthorns of Europe, is considerably used abroad as a laxative, and 


CATHARTICS. 


679 


contains a crystalline principle, Franguline , besides glucosides, of which 
Emodine is also found in rhubarb. In this country it is employed very 
rarely, but the bark of Rhamnus Purshiana, or California buckthorn, 
is very largely used under the name of Cascara Sagrada. It probably 
contains principles either identical with or allied to those found in the 
European bark. In many cases its fluid extract acts most happily as 
a laxative in habitual constipation , although sometimes it causes griping 
pains and irritation of the mucous membrane. The best results are 
usually to be obtained by giving from ten to fifteen drops of the fluid 
extract one or two hours after meals; rarely half a fluidrachm given 
at bedtime seems to suit better an individual case. 

Euonymus, U.S., or Wahoo, the bark of Euonymus atropurpureus, 
is, according to the experiments of Professor Rutherford, an active 
cholagogue in dogs, and given in the form of the fluid extract, or in 
that of the solid resinoid extract, euonymin, its effects are often most 
happy in cases of habitual constipation and hepatic torpor. It acts very 
slowly and purges only moderately. The dose of the fluid extract is 
a dessert- to a tablespoonful; of euonymin, two to four grains: in cases 
of dyspepsia it may be repeated with good results two or three times a 
week. The dose of the extract (Extractum Euonymi, U.S.) is three to 
six grains. 


MAGNESIA—LIGHT MAGNESIA. U.S. 

MAGNESIA PONDEROSA—HEAVY MAGNESIA. U.S. 

The heavy and the light magnesia differ only in their physical charac¬ 
ters, the particles being differently aggregated. The carbonate of mag¬ 
nesium, (Magnesii Carbonas, U.S.) is manufactured by precipitating a 
solution of sulphate of magnesium by one of carbonate of sodium. If 
the two solutions be concentrated, the dense or heavy carbonate falls; 
on the other hand, if the solutions be dilute, the precipitate is a light 
carbonate. Heavy magnesia is obtained by calcining a heavy car¬ 
bonate ; light magnesia, by using a light carbonate. All of these sub¬ 
stances are of a milk-white color, and occur in powder; the carbonates 
sometimes in ver}^ light cubical blocks. They are all practically insolu¬ 
ble in water, freely soluble in dilute acid, and in the presence of acids 
they all act as alkalies. 

Therapeutics. —Magnesia and its carbonate act in the same manner 
upon the human economy, being both antacid and laxative. For their 
purgative powers they are probably dependent upon the presence of 
acids in the primse vise, and hence their effects vary. They are some¬ 
times taken as habitual laxatives by persons suffering from acid dys¬ 
pepsia ; but, as they are said at times to accumulate in the intestines and 
to do harm mechanically, this use of them should be discountenanced. 
They are very frequently employed in conjunction with Epsom salt, 
senna, or other of the more powerful purgatives, on account of their 


680 


LOCAL REMEDIES. 


antacid properties. Their chief use is in acute acid dyspepsia, in sick 
headache, in some forms of diarrhoea with excessive acidity in children, 
in gout, rheumatism, and in various cutaneous affections, —wherever, in a 
word, a laxative antacid is indicated. 

Administration.— The dose of the carbonate is, for a child a year 
old, from five to twenty-five grains, according to the effect desired ; for 
an adult, half a drachm to half an ounce; that of the magnesia is about 
one-fifth less. 

SULPHUR. 

Sulphur is officinal in three forms: Sulphur Sublimatum, or Flowers 
of Sulphur; Sulphur Lotum, or Washed Sulphur; and Sulphur Prje- 
cipitatum, or Precipitated Sulphur. The first of these is made by sub¬ 
liming sulphur into cool chambers, and always contains some sulphuric 
acid, generated during the process. When freed from the acid by 
washing with warm water and ammonia, it constitutes the washed 
sulphur. The U.S. Pharmacopoeia directs the precipitated sulphur to 
be prepared by boiling lime and sulphur together, so as to form a 
sulphide of calcium, and precipitating this with hydrochloric acid. 

The sublimed and the washed sulphur occur as sulphur-yellow, crys¬ 
talline powders; the precipitated as a whitish powder, whose particles 
are often coherent into friable lumps. For an account of the various allo- 
tropic forms of sulphur, and its chemical properties, the reader is referred 
to works on chemistry. It is insoluble in water, but soluble in alkaline 
solutions, in alcohol, the fixed and volatile oils, chloroform, ether, etc. 

Physiological Action. —When applied locally, sulphur is almost 
without influence. Taken internally, it is dissolved to some extent in 
the alkaline intestinal juices and absorbed. It has been detected in 
the milk, sweat, urine, and even in the breath. It would appear to 
suffer oxidation in the system; at least its ingestion is followed by in¬ 
crease of the urinary sulphuric acid (Regensburger, Centralbl. f. Med. 
Wissen., 1877, 328). When in sufficient quantity, sulphur acts as a 
mild laxative, producing soft, semi-liquid, feculent stools, accompanied 
generally with much offensive flatus of sulphuretted hydrogen. It is 
affirmed that in some instances the latter gas has been so freely gen¬ 
erated and absorbed as to cause systemic poisoning. Cases have also 
been reported in which the flowers of sulphur acted as an irritant 
poison; but this, without doubt, has been owing to their containing a 
large quantity of sulphuric acid. Its continued use has probably some 
effect upon nutrition ; the secretions generally are slightly increased, 
and some have affirmed that the temperature is somewhat elevated; 
but the truth of this is certainly very doubtful. The results of clinical 
experience indicate that it has an especial tendency to act upon the 
skin and mucous membranes. 

Therapeutics. —As an habitual laxative, sulphur has been used with 
asserted advantage in cases of hemorrhoids and of chronic rheumatism. 
In subjects of the latter disease it is claimed that it exerts a beneficial 


CATHARTICS. 


681 


alterative influence, especially in sciatica and in lumbago and other 
varieties of muscular rheumatism. It has also been employed as an 
alterative in various cutaneous affections; and in the form of natural 
sulphur-waters, used externally and internally, there is much testimony 
as to its value in both rheumatic and skin diseases. It is affirmed by 
Dr. Doit ( Gaz . des Hopitaux , Oct. 24, 1885) that the natural sulphur- 
waters are of very great value in the treatment of chronic syphilis , as 
thoy undoubtedly are in chronic gout and rheumatism. They may be 
substituted by the artificial sulphur-water described under the heading 
of Expectorants. Sulphur is very largely used as a parasiticide in 
cases of itch. Dr. Tilbury Fox recommends its application in the fol¬ 
lowing manner. He says, “ I have applied to all papules and vesicles 
the following ointment: sulphur, half a drachm; ammonio-chloride 
of mercury, four grains; creasote, four drops; oil of chamomile, ten 
drops; and an ounce of lard. This is rubbed in night and morning for 
three days, especially to the interdigits and wrists ; the same shirt is 
kept on till the third day, when it is changed and a warm bath given. 
The use of the parasiticide for two or three days should be followed 
by a good washing and the discontinuance of the remedy for a night. 
If the patient be not troubled with itching during the night, we may 
conclude that the acari are killed, and all we need to do is to guard 
against the hatching-out of fresh acari by the light application of our 
parasiticide once a day to any ‘ pimply’ or itchy place for a few days 
longer, taking care that the foul clothes are well heated or scalded. 
‘ Not too strong and not too long,’ is my rule in the use of remedies for 
scabies. The occurrence of red, rough, erythematous patches is a sign 
that the remedy itself is creating a disease.” 

Administration. —Sulphur is generally given in powder, mixed with 
syrup or molasses. Dose, as an alterative, ten to twenty grains three 
times a day; as a laxative, one to three drachms at bedtime. 

Potassa Sulphurata.— Sulphurated Potassa is prepared by heating 
together sulphur and carbonate of potassium. It occurs in liver-brown 
fragments, which form an orange-yellow solution in water. Its taste is 
acrid, alkaline, and very disagreeable. When moistened, it feebly emits 
the odor of sulphuretted hydrogen. 

Locally applied, the sulphuret of potassium is a very decided irri¬ 
tant. Taken in large quantities, it is a violent corrosive poison, and is 
said to have produced fatal gastro-intestinal inflammation. In medicine 
it has until within a very short time been employed only externally. 
It has been used as a stimulating ointment (5ss to 3j) in various skin- 
affections, and is also used for the formation of sulphur-baths, the 
strength of which should vary, according to the requirements of special 
cases, from two to six ounces of the drug in thirty gallons of water. 
They should be taken warm, the patient remaining in from twenty 
minutes to two hours, and are said to cause a general excitement, 


682 


LOCAL REMEDIES. 


amounting in some susceptible persons to high fever. When employed 
strong, they sometimes occasion a papular eruption. They have been 
used in chronic rheumatism and in various scaly skin-diseases. 

Calx Sulphurata. TJ.S. Sulphurated Lime. —In the Lancet for 
February, 1874, Dr. Sydney Ringer recommended in the most laudatory 
manner sulphide of calcium in frequently-repeated doses of a tenth of 
a grain in boils when they appear in successive crops, and in various 
scrofulous and other unhealthy sores , such as occur especially in children, 
also in scrofulous glandular enlargements. The value of the remedy has 
been confirmed by Duhring and others; it is often given in half-grain 
doses. The Calx Sulphurata of the Pharmacopoeia contains not more 
than thirty-six per cent, of pure sulphide of calcium, but is the com¬ 
mercial article known by that name. 

PURGES. 

OLEUM RICINI—CASTOR OIL. U.S. 

A fixed, nearly odorless oil, of a nauseous taste, obtained from the 
seeds of Ricinus communis by expression. The seeds are slightly 
warmed before being put under pressure, so as to liquefy their con¬ 
tained oil; and the crude oil obtained from them is boiled with a small 
amount of water, so as to coagulate its albuminous impurities. The 
oil was formerly manufactured by means of alcohol, also by heating 
the seeds or by boiling them in water, and several varieties of it ex¬ 
isted ; but these are no longer in the market. Castor oil is remarkable 
for being soluble not only in ether, but also in alcohol. The castor-oil 
seeds , or beans , as they are commonly called, contain an acrid fixed 
principle, which makes them exceedingly poisonous. 

Physiological Effects. —Castor oil acts upon the human organism 
as a mild but decided purgative, producing copious fluid faecal discharges, 
and in overdoses sometimes vomiting, and always purging freely. It 
is a matter of some doubt whether the properties of the officinal oil 
are or are not due to the presence of a minute quantity of the acrid 
principle of the seeds; although the probabilities are in favor of the 
affirmative proposition. That the oil or its active principle is absorbed 
is proved by analogy, and by the facts that in children it sometimes 
purges when rubbed upon the skin of the abdomen (Canvane, quoted 
by Stille), and that when taken into the stomach it has been known to 
exude from the skin (Ward’s case, London Med. Gaz., vol. x. p. 377). 
In regard to its existence in the stools, the testimony is conflicting. 
Thus, Bucheim ( Virchow's Archiv. Bd. xii.), although he submitted the 
passages produced by it to careful chemical manipulation, failed to 
detect it or any of its derivatives in them; but Bird (quoted by Stille) 
and other observer's affirm that it can be seen by the eye in the dejecta, 
either as oil or in the form of caseous flakes. According to the experi- 


CATHARTICS. 


683 


ment (quoted by Stille) of Hale upon himself, half an ounce of castor 
oil injected into a vein produces malaise, nausea, faintness, anxiety, and 
general dulness and depression, without purging. 

Therapeutics. —On account of the mildness of its action and the 
especial property which it appears to have of soothing an irritated 
bowel, castor oil is constantly employed whenever it is desired simply 
to evacuate the intestinal canal; not so much, however, in chronic con¬ 
stipation as when a temporary action is alone required. In various in¬ 
flammatory or irritative affections of the alimentary canal, castor oil is 
of the greatest service, partly, no doubt, by removing acrid irritating 
secretions or foreign materials, such as undigested food, and partly by 
causing a depletion of the congested vessels, but also apparently by 
virtue of an almost specific power, which renders it the most satisfac¬ 
tory cathartic in these cases. This is especially seen in the acute diar¬ 
rhoeas and even in the chronic enteritis of children, but also holds good 
in the diarrhoeas and dysenteries of adults. 

Within the last few years a good deal has been written in regard to 
the use of the leaves of the castor-oil plant as a galactagogue, and suffi¬ 
cient evidence has been brought forward to render them worthy of 
some confidence. A poultice made of the fresh leaves should be applied 
to the breasts, and a teaspoonful of a fluid extract, prepared from the 
same, should be exhibited three or four times a day. 

Administration. —Castor oil is very repulsive to the palate, so much 
so as to nauseate, or even vomit, by its taste, some susceptible individ¬ 
uals. It has been the habit to administer it in emulsion with a strong 
mint-water, or to give it in the froth of porter or in a cup of hot coffee; 
but by far the best plan is to mix it with an equal part of glycerin and 
to add two or three drops of the oil of cinnamon or of gaultheria to 
each dose. The substances do not stay mixed, but separate on standing: 
when used, they may be made temporarily to recombine by shaking the 
bottle. As glycerin has feeble laxative power, an ounce of this mixture 
represents a little more than half an ounce of the oil. It should be 
taken directly out of the spoon. The full purgative dose of the oil is 
half an ounce to an ounce for an adult; for an infant a year old, one 
to two teaspoonfuls. In dysenteiy it is sometimes advantageous to 
give the drug in small dose every three hours until a decided purga¬ 
tive operation is induced. 

Toxicology.— Although castor oil is harmless, the beans contain an 
acrid principle which renders them exceedingly poisonous, three of 
them having sufficed to destroy the life of a man (Med. Times and 
Gaz., May, 1861). The symptoms do not usually come on until from two 
to five hours after the ingestion of the poison, when severe abdominal 
pain is felt, accompanied by violent vomiting and by purging, which 
after a time may become bloody, and soon ushers in a stage of collapse, 
with or without severe muscular cramps, with cold sweating skin, con¬ 
tracted features, thirst, restlessness, small rapid pulse, and sometimes 


684 


LOCAL REMEDIES. 


the general appearance of Asiatic cholera. After death, intense redness 
and even abrasion of the stomach and of the small intestine are found. 
The treatment should consist in the evacuation of the stomach and 
bowels by mild emetics, such as ipecacuanha and warm water, and by 
mild cathartics, such as castor oil, provided nature has not already 
sufficiently fulfilled the indications, and in the free use of opium and 
demulcent drinks, the early external application of leeches and of 
emollient poultices, and the swallowing of small pieces of ice: in other 
words, the treatment, after evacuation, should be that of acute gastro¬ 
enteritis. 

HYDRARGYRUM. U.S. 

The only preparations of mercury which are used as purgatives are 
calomel and blue mass. Of these the first is by far the more active, and 
indeed is the only one which can be relied upon to purge, since the 
pilulse hydrargyri very frequently will, if given by themselves, fail to 
induce liquid stools. 

The chief interest in the purgative action of mercurials centres in 
the question as to their influence upon the liver. The evidence at 
present derivable from experiments upon the lower animals has already 
been discussed, and the decision arrived at that it must be rejected.* 

When calomel is given to a healthy man in moderate purgative 
doses, green liquid stools are produced, which, after larger doses, are 
replaced by brown passages. The color of these passages has always 
been supposed by clinicians to be due to the presence of bile; but re¬ 
cently it has been affirmed that the green tint is owing to a compound 
of the mercury itself. Although no chemical proof of the presence of 
the metal or its salt has, that I am aware of, been furnished, yet it can 
scarcely be doubted that mercury is present in the first passages pro¬ 
duced by calomel. The question, evidently, is not, Is mercury ever 
present in the green stools? but, Is it always present? or, in other 
words, Is it an integrant portion of them ? The evidence is not so 
abundant upon this point as is desirable, yet seems sufficient to furnish 
a negative answer to the last question. Simon (.Animal Chemistry , 
Sydenham Soc. Transl., vol. ii. p. 386) and Golding Bird (London Med. 
G-az ., 1845, p. 801), in careful analyses, both failed to detect the metal; 
and, as the recognition of mercury is an exceedingly simple chemical 
problem, it seems impossible that these chemists could have overlooked 
the metal if it had been present. Simon’s analysis was performed upon 
the fifth stool after the administration of a large dose of calomel. The 
passage was fluid, perfectly green, had no faecal odor, exhibited a mild 
acid reaction, and showed under the microscope a great number of 
mucus-corpuscles and epithelium-cells. Ether extracted from the solid 
residue (obtained by evaporation) a considerable amount of fat, which 


* For a very elaborate review of the clinical evidence, see Dr. Thomas R. Fraser’s paper 
in the Edinb. Med. Journ., April, 1871. 



CATHARTICS. 


685 


had an acid reaction, contained cholesterin, and was colored by biliver- 
din. All the other substances which were separated from the stool by 
water and alcohol were more or less colored by bile-pigment. Bilin, 
bilifellinic acid, and biliverdin were found in large quantity. 

The most satisfactory evidence is, however, that furnished by Michea 
(Lancet, 1849, vol. i. p. 15), who examined chemically the faeces under 
four ditferent conditions. First, the spontaneous dejections of six 
healthy individuals: no bile was detected. Secondly, green stools of 
three persons suffering from gastro-intestinal derangement: bile-pig¬ 
ment was found in one case only, and in that could not be detected 
after persistent vomiting had ceased. Thirdly, calomel having been 
given to eight healthy persons, five men and three women, bile was 
readily demonstrated in the green passages produced in all of the 
subjects. Fourthly, saline and resinous purgatives were given to five 
persons, but no bile could be detected in the liquid stools. 

To the evidence brought forward in favor of the proposition that 
calomel given to healthy men causes an increased escape of bile from 
the alimentary canal, may be added the conclusive fact that in some 
persons, whose idiosyncrasies render them very susceptible to the action 
of calomel, it produces not merely purging, but also vomiting of bile, 
which is scarcely at all altered. 

From the facts which have just been passed in review, the conclu¬ 
sion seems inevitable that mercurial purgatives given to healthy persons 
cause the escape of large quantities of bile from the alimentary canal.* 

As is well known, when from any cause bile does not pass into the 
duodenum, the stools become very pale, of a peculiar potter’s-clay, or 
even white, color. Very frequently under these circumstances, which 
may coexist either with diarrhoea or with constipation, mercurials will 
modify the color of the passages and alleviate or cure any symptoms 
present. In many cases the mercurials are, of course, powerless to 
effect the desired result; but this depends upon the cause being organic, 
or of some other nature not to be overcome by a mere stimulant to 
secretion. 

As mercurials in health increase the flow of bile from the intestine, 
and as they will sometimes re-establish it in disease when the secretion 
has altogether ceased or has been very materially diminished, the con¬ 
clusion seems to me inevitable that mercurials have the power of di¬ 
rectly or indirectly increasing the secretion of bile. The only objec¬ 
tion of any force to be urged against this deduction is founded upon 
the idea that the drug simply increases peristalsis in such a way as to 
cause the bile naturally in the duodenum to be swept out instead of 
being absorbed. The answer to this is embraced in the following facts: 


* Dr. J. Zawadzky ( Vratch , 1887, abstracted, Bull. ThSrap ., 1887), as the result of his 
own researches, comes to the improbable conclusion that the presence of bile in the stools as 
the result of the use of calomel is due to the antiseptic property of the mercurial, the bilirubin 
being converted into biliverdin, which is prevented from undergoing decomposition. 



686 


LOCAL REMEDIES. 


mercurials restore the color of the passages when pale from arrested 
secretion, often without producing diarrhoea; other even more active 
purgatives fail to induce the same bilious passages; when diarrhoea 
exists with clayey stools, the change in the color of the passages caused 
by a mercurial may coincide with a not increased, or even a lessened, 
amount of liquidity; diarrhoea ordinarily does not cause bile to appear 
in the passages. 

Therapeutics. —A mercurial purge is especially indicated by the 
congeries of symptoms known as “ biliousness a heavily-coated tongue, 
bitter, disagreeable taste, heavy headache, depression of spirits, loss of 
appetite, slight nausea, and light-colored passages. It should be borne 
in mind that one or several of these symptoms may be absent in any 
individual case. Of all single indications for the use of calomel, the 
occurrence of potter's-clay-colored passages is the most important; and 
if such stools exist, and do not depend upon an organic cause, repeated 
small doses of mercurial should be given, whether there be constipation 
or diarrhoea. 

In bilious fever, — i.e., malarial fever with congestion of the liver, —a 
mercurial purge, or several mild mercurial purges, will often, by ex¬ 
citing the action of the hepatic gland, be of great service in preparing 
the way for or aiding in the action of quinine. In catarrhal jaundice , 
mercurials, on the whole, offer, I think, the most frequently successful 
mode of treatment. It is evident that in such cases calomel does good not 
merely by its cholagogue influence, but even to a greater extent by its 
antiphlogistic power, no doubt lessening the viscidity of the secretions 
and abating the inflammatory action in the hepatic ducts. In many 
instances it is well to exhibit a mercurial purge to start with; but 
the main reliance is to be placed in the continuous exhibition of small 
doses of the drug until the gums are rendered slightly sore. Anything 
like profuse salivation is, of course, to be avoided. In dysentery of an 
acute sthenic type, calomel has yielded, in my hands, better results than 
any other remedy. It probably acts as an antiphlogistic and as an 
alterative, not only to the liver, but to all the intestinal glands. It is 
possible that its influence for good in some cases is connected with its 
bactei’icidal powers, since Dr. N. P. Wassilieff ( Zeitschr . /. Physiol . 
Chem., 1882) has found that it has no effect in checking the action of 
the digestive ferments, but has a very pronounced influence in stopping 
putrefactive changes in food by killing the organisms which produce 
such changes. In one or two cases of obstructive enteritis, with severe 
constipation, which I have seen treated with this drug after the failure 
of other remedies, improvement in the local and constitutional symp¬ 
toms commenced simultaneously with slight ptyalism, and continued on 
to recovery. 

RHEUM—RHUBARB. U.S. 

The root of Rheum officinale, Baillon, and other species of Rheum 
growing in China, Chinese Tartary, and Tartaiy. 


CATHARTICS. 


687 


Rhubarb occurs in hard, irregularly cylindrical or roundish pieces, 
of a brownish-yellow color and peculiar bitter taste, and imparting to 
the teeth a sense of grittiness, due to the presence of great numbers 
of minute crystals of oxalate of calcium. There were formerly two 
chief varieties in market, the Russian and the Chinese. The first of 
these was the best, and was distinguished by the exterior of the pieces 
being cut or pared with a knife, and by a conical hole, evidently made 
for inspection with the point of a sharp instrument, and never reach¬ 
ing beyond the centre of the mass. The cause of the superiority of 
this brand of rhubarb was the close governmental inspection which it 
received on the Russian frontier. Such pieces as failed to pass the 
officials found their way into commerce through Turkey, and consti¬ 
tuted the so-called Turkey Rhubarb, which resembled the Russian in 
external characters, but was of somewhat inferior quality. The Chinese 
Rhubarb was distinguished by the outside of the pieces having been 
scraped, and by the existence of a large hole running clear through 
and often retaining a portion of the cord upon which the roots had 
been strung to dry. Owing to the expiration and non-renewal of the 
treaty between the governments of Russia and of Tartary, the only 
officinal variety of rhubarb now in the market is the Chinese. Besides 
the true varieties just named, there is a drug in commerce which 
from its source is known as European Rhubarb. It occurs in long, 
cylindrical pieces, or very often is cut to imitate one of the varieties 
of the genuine drug, from which it is to be distinguished by its more 
spongy texture and by the complete or almost complete absence of 
grittiness when chewed.* 

The active principles of rhubarb have not all been made out: it 
certainly contains chrysophanic acid, and a peculiar tannic acid, to 
which it owes its astringency. Chrysophanic Acid f crystallizes out of 


* In the past, the European rhubarb has been considered of little value; but recently it 
has been claimed that it is as good as the Asiatic. See U.S. Dispensatory, 13th ed., p. 735; 
also Professor Radius ( Apotheker Zeitung, Bd. vi., 1871). 

f Under the names of Goa Powder and of Araroba or Chrysaroba have long been used in 
Brazil and the East Indies certain powders, varying from fine to coarse and from a light 
yellow to a dark chocolate, which are now known to be identical, and the product of a Bra¬ 
zilian tree. They depend for their activity upon chrysophanic acid, of which Squier states 
they frequently contain as much as sixty-five per cent. Dr. I. Ashburton Thompson has 
found that from six to eight grains of this acid, taken internally, after about four hours pro¬ 
duce vomiting, sometimes repeated at intervals and sometimes followed by purging {Brit. 
Med. Journ., May, 1877). The slowness of the results he believes to be due to the difficulty 
of absorption. The only practical application of the Goa powder or its active principle is in 
certain skin-diseases, especially in psoriasis. According to the researches of Dr. Balmanno 
Squier, its power in this disorder is extraordinary. He uses an ointment made by dissolving 
the acid in hot lard (gr. v to £ij in ^i), cooling, and mixing thoroughly with a pestle. The 
ointment sometimes produces excessive irritation : hence it is advised to commence with a 
strength of not more than twenty grains to the ounce, well rubbed in twice daily. The acid 
stains of a dark purple; this can be removed from hair, underclothes, etc., by hot benzole, if 
no soap or alkali has been used. The skin and nails are said to contain enough potash to 
set the dye. 



688 


LOCAL REMEDIES. 


alcohol in orange-yellow, golden, shining needles; out of benzole in 
orange-yellow or pale six-sided rhombic plates; with nitric acid it pro¬ 
duces a fine yellow color; with the alkalies, a beautiful purple-red. 
According to Schlossberger, Bucheim, Meykow, and Auer, it is not 
purgative; but Schroff has found it to be so.* It certainly is not the 
chief purgative principle of the drug. The substances known as Rhein 
and Rhabarbarin are complex bodies. 

Physiological Action. —Bhubarb is somewhat stomachic, tonic, 
actively purgative, and, owing to its tannic acid, secondarily astrin¬ 
gent, leaving a decided tendency to constipation after the primary 
purgation. Owing probably to its chrysophanic acid, it gives a yel¬ 
lowish color to the milk of nursing women and to the urine. Bhubarb 
urine is to be distinguished from that of jaundice by its becoming 
purplish-red on the addition of an alkali. Bhubarb is asserted to 
affect chiefly the muscular coat of the bowels, and to purge by in¬ 
creasing peristalsis; but I have never met with any proof of this 
common belief. 

Therapeutics. —Notwithstanding its astringent property, rhubarb 
is largely used as an habitual laxative, because it does not impair, but, 
on the contrary, seems to strengthen, the appetite and the digestion. 
It should not be used in a high sthenic state of the system, or when 
depletion is necessary, but it is, on the other hand, the best purgative 
when it is desired simply to unload the bowels in a debilitated subject. 
In diarrhoea , with intestinal weakness or relaxation, it is the best pur¬ 
gative with which to unload the bowels of acrid secretions retained in 
them; and in the form of the aromatic syrup combined with an alkali 
it is especially valuable in the summer bowel-complaints of children when 
the stools are greenish and mucous. 

Administration. —Bhubarb is seldom employed in powder, but, 
when used, may be given in the dose of twenty grains. In chronic 
constipation, small pieces of the root are very often carried in the 
pocket and chewed by the person affected pro re nata. The U.S. Phar¬ 
macopoeia recognizes the following preparations: Extractum Rhei, —dose, 
five to ten grains; Pilulce Rhei, each containing three grains of rhubarb; 
Pilulce Rhei Composite (two grains of rhubarb, one and a half grains of 
aloes),—dose, two to four pills; Pulvis Rhei Compositus (rhubarb and 
magnesia),—dose, half a drachm to a drachm ; Extractum Rhei Flwidujn , 
—dose, twenty to thirty minims; Syrupus Rhei, —dose, for an infant, a 
fiuidrachm; Syrupus Rhei Aromaticus, —dose, for an infant, a fiuidrachm ; 
Tinctura Rhei, —dose, one to two fluidrachms; Vinum Rhei, —dose, one 
to four fluidrachms; Tinctura Rhei Aromatica, —dose, one-half to one 
fiuidrachm; Tinctura Rhei JDulcis, —dose, two to three fluidrachms. 
The aromatic preparations are of pleasant taste and efficient, and are 
much used for children. 


* See Die Pfianzenstoffe, p. 985. 




CATHARTICS. 


689 


Juglans. TT.S.—The inner bark of the root of Juglans cinerea, the 
common butternut, or white walnut. Juglans is said to be a mild ca¬ 
thartic, resembling rhubarb in its action, as a substitute for which it 
was introduced during the Revolution by the famous Dr. Rush. The 
dose of the extract (Extractum Juglandis , U.S.) is twenty grains. 

ALOE—ALOES. U.S. 

There are three commercial varieties of aloes, which are all obtained 
in a similar manner,— i.e., by cutting off the thick, succulent leaves of 
the various plants, standing them up, allowing the juice to drain into 
suitable vessels, and afterwards inspissating, either by exposure to the 
sun or by slowly evaporating. The leaves contain a very large amount 
of a thick, mucilaginous juice, which escapes on pressure: hence aloes 
prepared by expressing the leaves or by boiling them—both of which 
processes are sometimes practised—is very inferior. Socotrine Aloes is 
the product of Aloe Socotrina, which grows in the island of Socotra 
in the Indian Ocean, and on the southern coast of Arabia. It alone is 
recognized by the U.S. Pharmacopoeia. Barbadoes Aloes is prepared 
in Barbadoes and other West Indian islands, from Aloe vulgaris. 
Cape Aloes is obtained in the Cape Colony, South Africa, from Aloe 
spicata. 

Aloes are darkish extracts, of a bitter, nauseous taste, yielding their 
virtues to alcohol, imperfectly to water, and very perfectly to alkaline 
solutions. The Cape aloes is said to be “ characterized by its dark-olive 
or greenish-black color, its smooth and very glossy surface when broken, 
its translucency at the edges, and the fine bright-yellow color of its 
powder, which is slightly tinged with green.” The Socotrine aloes is 
distinguished by its yellowish-brown or reddish-brown color, its trans¬ 
lucent edges, agreeable aromatic odor, and beautiful golden-yellow 
powder. The Barbadoes aloes is characterized by its dark-brown or 
reddish-brown color, its dull fracture, opaque edges, disagreeable nau¬ 
seous odor, and dull olive-yellow powder. Of these varieties the Soco¬ 
trine is most esteemed in human medicine. The Barbadoes is said 
to be the strongest, but is employed almost exclusively in veterinary 
surgery. 

Messrs. T. and H. Smith ( Chem. Gaz., 1851) in 1850 discovered in 
Barbadoes aloes a crystalline principle,—aloin,—which was shortly 
afterwards found by Pereira to exist already crystallized in the sap of 
various species of aloe-plants, and was subsequently obtained by Groves 
( Pharm. Journ ., xvi.) from Socotrine aloes. Aloin crystallizes from its 
watery solution in sulphur-yellow granules, from a hot alcoholic solution 
in star-like groups of needles. It is neutral, odorless, of a taste at first 
sweetish, afterwards intensely bitter; is soluble with difficulty in cold 
water, freely in boiling water and in alcohol. There are three varieties 
of aloin,— barbaloin, socaloin, and nataloin, obtained respectively from the 
Barbadoes, the Socotrine, and the Cape aloes. The aloin of the markets 

44 


690 


LOCAL REMEDIES. 


is usually an amorphous bright powder, and probably of various consti¬ 
tution. The statements regarding the purgative properties of aloin are 
exceedingly contradictory, some physicians finding it a drastic purge 
in doses of one or two grains, others declaring that fifteen grains of it 
have no effect, while others affirm that it is a mild purge. It is evident 
either that various substances have been used under the same name,- 
or else that aloin owes its purgative properties to some impurity that 
adheres to it closely.* In my experience the commercial aloin is a 
moderately active cathartic in doses of one grain. An elegant laxative 
combination is aloin, half a grain, atropine, one-hundredth of a grain, 
strychnine, one-fortieth of a grain,— dose, one to two pills. 

Physiological Action.— Aloes is a stomachic, stimulant cathartic, 
remarkable for the slowness of its action. It has been supposed to 
influence chiefly, if not solely, the large intestine, and the clinical evi¬ 
dence is very strong that in overdoses it produces irritation of the rec¬ 
tum. The belief, formerly universal, that it is capable of producing 
hemorrhoids, has been very much weakened by the researches of a 
number of modern observers, among whom may be mentioned Trous- 
seau and Pidoux (Stille, Therapeutics, vol. ii. p. 444). Its habitual use 
in large doses is said to cause tenesmus, a feeling of weight, heat, and 
uneasiness in the pelvis, and occasionally excitation of the sexual organs. 
Although I have used it a good deal, however, I have never seen these 
results. It undoubtedly has a tendency to increase the menstrual flow. 
Aloes is certainly absorbed, as is shown by the fact attested by Dr. 
Gerhard (North American Med. and Surg. Journ.) and other observers, 
that it will purge when its powder is sprinkled upon a blistered surface. 
Aloin has also been detected in the urine by Dr. J. Dietrich ( Inaug. 
Diss., Dorpat, 1885). Professor Stille states that when other and 
quickly-operating cathartics are taken along with aloes it does not ap¬ 
pear to modify their action, but that if it is administered seven or eight 
hours before a saline or other active purgative, a combined and very 
powerful operation is the result. 

Therapeutics.— Aloes in small doses is one of the best remedies for 
constipation of atonic subjects, especially when a stomachic stimulant is 
indicated. In these cases it may often with great advantage be com¬ 
bined with a simple bitter, one or two grains of it taken directly after 


* Consult Chem. Gaz., 1851; Die Pjianzenstoffe, p. 1047; Trans. Brit. Pharm. Soc., 1872; 
Brit. Med. Journ., i., 1887, p. 747; Bull. Thgrap., xci. 259; Lond. Med. Record, 1877, p. 
459; Edinb. Med. Journ., xx. 1002 ; xxii. 1087. Dr. Fronmiiller (Med. Chir. Centralbl., 
1879, xiv.) says that one to three grains of Merck’s aloin dissolved in hot water admin¬ 
istered hypodermically acts as an efficient purge; while Dr. R. Kohn affirms that he has used 
both aloes and aloin of three different commercial varieties hypodermically without effect, 
giving ten times the dose employed by Fronmiiller. In the lower animals Kohn found the 
hypodermic injections to cause gastro-enteritis with albuminous urine, and a peculiar in¬ 
flammation of the kidneys: 0.1 grm. of Merck’s aloin for every kilogramme of bodily weight 
was found to be a fatal dose for the dog. Aloin could be detected in the urine. (Method of 
analysis given.) Schmidt’s Jahrb., cxciv. 246. 




CATHARTICS. 


691 


meals being generally sufficient. In the constipation of plethora it 
should not be employed; neither should it be administered when active 
abdominal or rectal inflammation exists. During pregnancy it may be 
used as a laxative, but, unless some especial indication calls for its use, 
it is best avoided. Large purgative doses of it should never be given 
to pi*egnant women, as it certainly irritates the pelvic organs, and is 
even said to have the power of causing abortion. Formerly it was 
taught that aloes should not be used in hemorrhoids; but most, if not all, 
of the cases of this affection depend upon a condition of relaxation of 
the rectal veins, and Dr. Fordyce Barker ( American Practitioner , 1872) 
insists upon the gi’eat value of aloes in piles, and states that Oppolzer 
was especially famous for his treatment of this affection, and that his 
prescriptions were, when piles are associated with constipation, aloes 
and quinine; without constipation, aloes and sulphate of iron. For 
bleeding piles he used R—Ferri sulphat., 3i; Ext. aloes aq., 3i; Ext. 
taraxaci, q. s. Ft. pil. no. 60. S.—One morning and evening, and in¬ 
crease to three a day if necessary. When costiveness accompanies 
atonic amenorrhcea, aloes alone of all the laxatives should be exhib¬ 
ited ; and it is also of service in atonic menorrhagia. 

Administration. —Aloes is very rarely or never used by itself to 
produce free purgation, but may be given in the dose of from ten to 
twenty grains; in the dose of from three to five grains it is a decided 
laxative. As aloes often contains sticks and other extraneous matters, 
the U.S. Pharmacopoeia directs that an Aloe Purificata , or Purified Aloes, 
should be made by dissolving the crude drug in alcohol, straining, and 
evaporating. The preparations are: the tincture ( Tinctura Aloes, —1 to 
10, U.S.),—dose, as a laxative, one to three teaspoonfuls; the tincture of 
cdoes and myrrh, Elixir Proprietatis ( Tinctura Aloes et Myrrhce ,—aloes 
and myrrh, aa 1 to 10, U.S.),—dose, as a laxative, one to two teaspoon¬ 
fuls ; the wine ( Vinum Aloes ,—6 to 100, U.S.), which contains also car¬ 
damom and ginger,—dose, as a laxative, one-half to one teaspoonful; 
the pills (Pilulce Aloes, U.S.), which contain each two grains of aloes 
and two grains of soap; the Pills of Aloes and Asafetida ( Pilulce Aloes 
et Asafcetidce, U.S.), useful in eostiveness of hysterical or old subjects, 
each pill containing four grains of a mass composed of equal propor¬ 
tions of aloes, asafetida, and soap; the Pills of Aloes and Mastich 
( Pilulce Aloes et Mastiches, U.S.), the famous “ Lady Webster Dinner- 
Pill,” each containing two grains of aloes; the Pills of Aloes and Myrrh 
(Pilulce Aloes et Myrrhce, U.S.), used in amenorrhcea, and containing two 
grains of each ingredient in every pill; the Pills of Aloes and Iron 
( Pilulce Aloes et Ferri, U.S.), containing each one grain of aloes and one 
of dried sulphate of iron. 

SENNA—SENNA. U.S. 

The leaflets of the shrubs Cassia acutifolia and C. obovata, of Nubia 
and Upper Egypt, and of C. elongata, of Southern Arabia. The senna- 


G92 


LOCAL REMEDIES. 


leaves vary from three-fourths of an inch to an inch and a half in 
length, and are to be distinguished by the inequality of their bases, the 
two sides of the lamina or leaf-blade joining the midrib at unequal 
heights and angles. There are three commercial varieties of senna, 
which are named from the places of their export. Alexandria Senna, 
the most common variety, is distinguished by the presence of the 
shorter argel-leaves, with equal bases, by the ovate-pointed leaflets of 
Cassia acutifolia, and by the scattered mucronate-obovate leaflets of 
C. obovata. India Senna is characterized by the oblong leaflets, from 
one to two inches in length, entire and perfect. Tripoli Senna may be 
recognized by the great extent to which the leaflets are broken up. 
The active principles of senna have not been completely isolated, but 
appear to be several. Cathartic Acid, discovered by DragendorfF and 
Kubly ( Vierteljahres. f. Prakt. Pharm., Bd. xvi.), is undoubtedly actively 
cathartic, as Kubly found that fifteen grains of it dissolved in an alka¬ 
line solution produced in six hours frequent watery discharges, with 
griping. R. Stockmann ( Arch, f . Exper. Path. u. Pharm., xix. 120) has 
confirmed the statements of Kubly, and devised a process for the pre¬ 
paring of cathartic acid in considerable quantity. He has also found 
that the neutral solution of cathartic acid in alkalies given to rabbits 
by the mouth produced after some hours violent diarrhoea, which, if 
the dose had been sufficient, continued until death. Post-mortem ex¬ 
aminations revealed hypercemia of the intestine. When injected into 
the blood or given subcutaneously, the salt of cathartic acid failed to 
affect the rabbit. It is probable, however, that cathartic acid, although 
the chief, is not the sole purgative principle in senna-leaves, since 
Bourgeois and Bouchut (_Z7 Union Pharm., Nov. 1871) found besides 
cathartic acid a clirysophanic acid, and a purgative principle which has 
not as yet been isolated, and may be an educt from the cathartic acid. 
The cathartine of the older writers is undoubtedly a complex body. 

Physiological Action.— Senna is a very powerful cathartic, pro¬ 
ducing watery faecal discharges, and acting, it is said, as readily upon 
swine, dogs, cats, and horses as upon man. According to Professor 
Stille, both Courten and Regnaudot found that its infusion injected into 
the veins caused vomiting and purging. It is undoubtedly absorbed ; 
and Bergius affirms that it will impart its purgative property to the 
milk of nursing women. 

Therapeutics. —Whenever a brisk, somewhat irritating cathartic is 
desired, senna may be selected. When given alone, it is very apt to 
gripe severely, and is consequently more often used in combination,— 
especially its infusion with Epsom salt ( Black Draught). In obstinate 
fcecal accumulation the Black Draught constitutes a most efficient and 
safe remedy. It is claimed that senna does not leave a tendency to 
constipation after its action; and hence, in small doses, it is preferred 
by some as an habitual laxative. 

Administration.— Whenever senna is exhibited, an aromatic should 


CATHARTICS. 


693 


be united with it, to lessen its tendency to gripe. The leaves are not 
given in substance. The dose of the fluid extract (Extractum Sennce 
Fluidum , U.S.) is two fluidrachms to half a fluidounce; the confection 
( Confectio Sennce , U.S.) is a very complex but elegant preparation, used 
only as a laxative, in doses of one to two drachms, especially in preg¬ 
nancy , and not suited to dyspeptic cases, on account of its tendency 
to derange the digestion. Infusum Sennce Compositum, U.S. ( Black 
Draught ), contains manna and sulphate of magnesium,—a very active 
hydragogue purge,—dose, four fluidounces; the dose of the syrup 
( Syrupus Sennce, U.S.) is one to four fluidrachms; the Pulvis G-lycyr- 
rhizce Compositus, U.S., or compound liquorice powder, is an excellent 
pleasant laxative in doses of thirty to sixty grains. 

Magnesii Sulphas, U.S.— Sulphate of Magnesium , or Epsom Salt , is 
now manufactured on a large scale from dolomite, the double carbonate 
of calcium and magnesium, and from native siliceous hydrite of mag¬ 
nesium. Sulphate of magnesium ordinarily occurs in small, acicular, 
slowly-efflorescent crystals, containing about fifty-one per cent, of water 
of crystallization, soluble in their own weight of water at ordinary 
temperatures. By proper precautions, it may be obtained in large 
quadrangular prisms terminating in a four-sided pyramid or a dihedral 
summit. The taste is bitter, saline, nauseous. 

Physiological Action. —Epsom salt is a most active hydragogue 
cathartic, producing very large watery discharges without causing any 
irritation of the intestines. In very large doses it is, however, capable 
of producing fatal hypercatharsis; and Christison reports the case of 
a boy, ten years old, said to have been killed by two ounces of the salt, 
without the induction of purgation. Injected into the veins of the dog 
or rabbit it is a deadly poison, causing death by failure of respiration, 
and also depressing the heart (Dr. J. H. Kecke, Inaug. Diss., Gottingen, 
1881; also Dr. M. Hay). According to Curci ( Lond. Med. Rec., Oct. 
1886), the soluble salts of magnesium first increase the blood-pressure and 
slow the pulse, and then lower the blood-pressure and quicken the pulse, 
with final cardiac paralysis. As the rise of the arterial pressure is pre¬ 
vented by previous destruction of the vaso-motor centre, it is probably 
the result of centric stimulation.* 

Therapeutics. —Whenever, in inflammation, it is desired to deplete 


* The action of the saline purgatives upon the tissue-changes of the body has been labo¬ 
riously investigated by a large number of chemists, with results which are so discordant that it 
does not seem at present possible to come to any conclusion. The whole drift of the evidence, 
however, seems to me to show that the direct action upon tissue-change is very slight, and 
that it is incapable of producing a definite and fixed result amidst the varying and compli¬ 
cated daily causes which inevitably produce more or less disturbance and variation in the 
nitrogenous elimination. An elaborate research upon the subject has been published by Dr. 
London in the Zeitschr. f. Klin. Med., Bd. xiii., Heft 1. Most of the literature of the subject 
will be found in this article, the original work of which seems to lead to the conclusion just 
stated. 



694 


LOCAL REMEDIES. 


through the bowels, the sulphate of magnesium offers the most advan¬ 
tageous method of doing it. Especially is this the case when the intes¬ 
tines are affected, as in enteritis or colitis. There is probably no other 
purgative in common use which produces at the same time such free 
serous evacuations and so little intestinal irritation. On account of 
the efficiency of its action and the watery character of its discharges, 
it is especially applicable to cases of fcecal accumulation and of obstinate 
colica pictonum. The dose is half an ounce to an ounce, properly diluted. 
M. Luton affirms that ten centigrammes (1.53 gr.) administered hypo¬ 
dermically usually provoke several watery stools ( Gaz. Hebdom., 1874, 
p. 455); but the practice seems to me a very doubtful one. 

Liquor Magnesii Citratis, U.S. — Solution of Citrate of Magnesium 
is prepared by putting into a strong bottle a syrupy solution of citrate 
of magnesium containing an excess of citric acid, adding bicarbonate 
of potassium, and corking tightly. On account of its agreeable taste 
and effervescence, this preparation is much used as a purgative. It 
is similar to Epsom salt in its action, but is less efficient, more apt to 
gripe, and more irritating. It ought not to be used in inflammatory 
affections of the bowels. 

♦ 

Magnesii Citras Granulatus, U.S. — Granulated Citrate of Magne¬ 
sium contains less free acid than the solution, and is therefore some¬ 
what less pleasant to the taste. The dose is one to three teaspoonfuls 
taken in solution while effervescing. 

Sodii Sulphas, U.S.— Sulphate of Sodium , or Glauber's Salt, is at 
present manufactured from common salt by means of sulphuric acid. 
It occurs in six-sided, very efflorescent, striated prisms, which finally 
crumble into a white powder. Its taste resembles that of Epsom salt, 
but is more nauseous. On this account, and because its action upon 
the economy is similar to but harsher than that of the sulphate of 
magnesium, in human medical practice it has been completely super¬ 
seded by the latter salt. Dose, one-quarter to one-half ounce. 

Sodii Phosphas, U.S. — Phosphate of Sodium occurs in colorless, 
transparent crystals, which effloresce and become opaque on'exposure. 
It is a tribasic phosphate, one part of water acting as a base. It is 
soluble in four parts of cold water, and has a saline taste, closely re¬ 
sembling that of common salt. In large doses it is said to be a mild 
saline purgative, but as such is at present very rarely used. Within a 
few years the use of the phosphate of sodium in chronic infantile diar¬ 
rhoea has attracted a good deal of notice. Originally recommended, so 
far as I know, by Dr. Eouth, in his work on Infant-Feeding, as being a 
valuable nutrient or alterative in children, attention has been especially 
drawn to the phosphate of sodium by Dr. William Stephenson ( Edinb . 


CATHARTICS. 


695 


Med. Journ., 1867, vol. xiii. p. 336). He believes that it acts upon the 
liver, and adduces much clinical evidence in favor of his views. The 
cases in which he especially recommends it are “ infants who are being 
artificially reared, and who ai*e liable to frequent derangement of the 
bowels; also when the phosphatic elements in the food seem deficient; 
where, from the character of the motions, there is a deficient or defec¬ 
tive secretion of bile. It is thus of service in cases of chalky stools or 
white fluid motions, and in many cases of green stools; also in duo¬ 
denal dyspepsia, and in diarrhoea and weaning.” Dr. S. Gf. Webber 
(.Boston Med. and Surg. Journ., 1868, vol. i. p. 5) confirms these state¬ 
ments, and I have seen very notable effects from this use of the drug. 

Potassii et Sodii Tartras, U.S.— Tartrate of Potassium and Sodium , 
or Rochelle Salt , is made by the addition of the carbonate of sodium to 
a solution of the bitartrate of potassium. It occurs in large, colorless, 
transparent, slightly efflorescent, prismatic or half-prismatic crystals, 
which are soluble in two and a half parts of cold water, and have a 
slightly saline taste. It is a mild saline purgative, decidedly less effi¬ 
cient, but much less offensive to the palate, than Epsom salt. The dose 
is from half an ounce to two ounces, properly diluted. 

Pulvis Effervescens Compositus, U.S.— Seidlitz Powder is in two 
packets, the white paper containing thirty-five grains of tartaric acid, 
the blue paper forty grains of the bicarbonate of sodium and two 
drachms of Rochelle salt. When they are taken, the powders are dis¬ 
solved separately, the solutions added, and the whole drunk while 
effervescing. They are very acceptable to the stomach, refrigerant 
and laxative rather than purgative. Seidlitz powders are used almost 
exclusively to evacuate the bowels, and exhibited after blue mass to 
“ carry off ” mercurials, etc. They should be taken on an empty 
stomach, as before breakfast. One powder is the usual dose; but not 
rarely even two powders will fail to purge. 

Potassii Sulphas, U.S. — Sulphate of Potassium, or Vitriolated Tar¬ 
tar, was formerly used as a purgative, but is no longer employed in 
medicine, except in the preparation of Dover’s powder. 

Sulphovinate of Sodium has recently been brought forward as a 
substitute for Epsom salt. A very great advantage is claimed for it, in 
that it has a refreshing flavor with very slight bitterness, and when 
given in flavored syrups makes a very pleasant drink. Its action is 
said to be rapid and thorough. The dose is two to four drachms for 
children, four to six drachms for an adult. 

DRASTICS. 

As already stated, the drastics are those vegetable cathartics which 
are actively irritant. With perhaps one or two exceptions, in sufficient 


696 


LOCAL REMEDIES. 


amount they are capable of causing fatal gastro-intestinal irritation. 
The line between the drastics and the stronger purgatives is, of course, 
placed more or less arbitrarily, since the various cathartics differ in 
action almost by insensible degrees. Thus, jalap, although included 
among the drastics in this work, might with perhaps even greater pro¬ 
priety be classed among the purgatives, since it is very little more 
active or irritant than is senna. Further, these remedies in combina¬ 
tion seem to lose, in a measure, their power of causing irritation, and 
to become useful purgatives. A fact, however, which makes the classi¬ 
fication here employed clinically useful, although it be not scientifically 
accurate, is that none of these remedies should be used when a purga¬ 
tive is desired to relieve gastro-intestinal inflammation or irritation; and, 
on the other hand, when a revulsive action is wished for, as in some 
cases of brain-disease, one of the drastics should always be selected. 

JALAPA.—JALAP. U.S. 

The tuber of Exogonium purga, a convolvulaceous vine growing in 
Mexico. Jalap comes into the market in two forms: one, that of the 
younger roots, which are sold undivided; the other, that of the old 
roots, which are brought into the market in transverse or longitudinal 
slices, and in pieces. The first variety consists of very hard, irregularly 
globular, brittle roots, about the size of a shut fist, or smaller, and often 
slashed with vertical incisions, made for the purpose of facilitating 
drying. The section of jalap is always distinctly resinous, if not to the 
naked eye, at least to the vision aided by a lens. The active principle 
is a duplex resin, one portion of which is soft, and soluble in ether, the 
other ( Rhodeoretin ) hard, and insoluble in the latter menstruum. Kho- 
deoretin is assex*ted by both Ivayser and Mayer (U.S. Dispensatory) to 
be the purgative principle; but Mr. J. C. Long (Amer. Journ. of Pharm ., 
1861) has shown that the soft resin is equally active. The percentage 
of resin varies very much in different specimens, but is much greater 
in those that are worm-eaten. 

Physiological Action. —Upon dogs and horses jalap (Stille, Thera¬ 
peutics , vol. ii.) is said to act as a powerful hydragogue cathartic, and 
in overdoses as a gastro-intestinal irritant. Its active principles are ab¬ 
sorbed, since Cadet de Gassicourt produced diarrhoea in dogs by the free 
application of jalap to the shaven skin, and J. Muller found the resin in 
the blood of dogs to which he had given it (lnaug. Diss., Dorpat, 1885). 
Professor Stille, however, asserts that it does not impart its purgative 
properties to the milk of nursing women, and that in man it is not 
absorbed by the skin. In man jalap produces free hydragogue catharsis, 
often with nausea; or, if in overdoses, violent vomiting and purging. 

Therapeutics.— Jalap is especially indicated when it is desirable to 
produce large watery stools. It is, however, very rarely used alone. 
A favorite combination with many practitioners is of it and calomel. 
In the form of the compound powder (Pulvis Jalapce Compositus, U.S.,— 


CATHARTICS. 


697 


jalap, thirty-five parts, cream of tartar, sixty-five parts), jalap is very 
frequently used with great advantage in ascites and also in other forms 
of general dropsy. It is believed when given in this way to exert some 
influence upon the renal functions: for very many cases the proportion 
of cream of tartar in the officinal compound powder is too small, and 
should be increased. 

Administration.— The dose of powdered jalap is ten to twenty-five 
grains, of the abstract (Abstraction Jalapce, U.S.), five to thirteen grains. 
The resin (Resina Jalapce , U.S.), like the other purgative resins, is pre¬ 
pared by precipitating a saturated tincture with water. According to 
Husemann, the ordinary adulterations of jalap resin may he detected 
by the solubility of the substances employed in the oil of turpentine, 
which does not affect the genuine article. On account of its tasteless¬ 
ness, this preparation, as well as the similar one of scammony, is some¬ 
times employed as a purgative for children. The dose for an adult is 
from two to four grains. 

COLOCYNTHIS—COLOCYNTH. U.S. 

The fruit, deprived of its rind, of Citrullus Colocynthis, or bitter 
cucumber, a vine growing in South Africa, Japan, Syria, Egypt, Turkey, 
the islands of the Grecian Archipelago, etc. The fruit is a round gourd, 
from two to four inches in diameter, of a whitish or pale-yellow color. 
It occurs in the market with or without its rind. The pulp is dry and 
membranous, whitish, and contains the active purgative glucoside Colo- 
cynthin, first discovered by Herberger. 

Physiological Action.— The experiments of Orfila and Schroff 
have shown that upon dogs and rabbits colocynth acts very much as it 
does in man, producing copious watery evacuations, and, although not 
so irritant as gamboge, in overdoses causing death by gastro-intestinal 
irritation. If the statement of Kichter that violent purgation may be 
induced by rubbing the abdomen with tincture of colocynth be true, 
the active principle is without doubt absoi’bed. 

Therapeutics. —Colocynth is rarely, if ever, used alone, but is given 
in combination with the other drastics, or with milder purgatives, to 
increase their activity. It is frequently added in small quantity, with 
advantage, to laxatives, especially when the constipation is somewhat 
obstinate. Its minute bulk is often of great advantage in these cases. 
Neither colocynth nor any of its combinations should be used in dropsy. 

Toxicology.— Colocynth has not rarely produced death, preceded 
by hypercatharsis and the usual symptoms of gastro-intestinal irrita¬ 
tion. The fatal dose probably varies very much. Christison records 
the death of a woman twenty-four hours after taking a teaspoonful and 
a half of the powder. Eoques chronicles a fatal result produced by 
less than a drachm of the powder in decoction, but, on the other hand, 
narrates a case in which three drachms failed to kill (Husemann, Hand- 
buck der Toxicologie , p. 625). 


698 


LOCAL REMEDIES. 


Administration. —Colocynth is used only in the form of the extract 
{Extractum Colocyiithidis, U.S.),—useful as an addition to laxatives,— 
dose, as a purgative, three to five grains; and of the compound extract 
(Extractum Colocynthidis Compositum, U.S.), which contains extract of 
colocynth, sixteen parts, purified aloes, fifty jiarts, resin of scammony, 
fourteen parts, cardamom, six parts, soap, fourteen parts, and is a very 
useful purgative preparation, either as a laxative in minute dose (one 
to three grains), or in large dose (five to twenty grains) as an active 
purgative. 

SCAMMONIUM—SCAMMONY. U.S. 

A resinous exudation from the root of Convolvulus Scammonia, a 
vine growing in Syria. It is said to be obtained by cutting off the 
root obliquely about two inches from the origin of the stems, and catch¬ 
ing in shells the few drachms of milky juice which exude from each 
root. From these shells it is emptied into a vessel and allowed to con¬ 
crete. Before exportation it is usually adulterated with the expressed 
juice of the leaves and stalks, and with chalk, flour, ashes, sand, etc. 
This adulteration was formerly carried to a very great extent, but is at 
present indulged in to a much less degree. The pure or Virgin Scam¬ 
mony is in irregular, rough, fissured masses, of various sizes, commonly 
solid, with a dull resinous fracture, and of a dark greenish color, in¬ 
clining to black. The smell is peculiar, resembling that of old cheese. 
The taste after a time is acrid. Factitious or adulterated scammony 
occurs in cakes of various sizes and shapes, and is sometimes spoken 
of as amylaceous or cretaceous scammony, according to the material used 
for its adulteration. The active principle of scammony is a resin, very 
similar to that of jalap. The proportion of this resin in the drug varies, 
according to the purity of the article, from eight to ninety per cent. 
The U.S. Pharmacopoeia directs that scammony shall contain seventy- 
five per cent, of the resin. 

Therapeutics. —Scammony acts upon the system like jalap, but is 
somewhat more irritating, and therefore more apt to gripe severely, 
and is still more strongly contra-indicated in inflammatory diseases of 
the intestinal canal. It is decidedly less drastic than gamboge. It is 
never used alone, but in combination with other less active cathartics. 
The dose of the resin (Resina Scammonii, U.S.) is two to five grains. 

As all the ingredients have been noticed, the present seems the 
proper place for the consideration of Pilule Cathartics Composite, 
U.S.— Compound Cathartic Pills. These popular pills contain each— 
compound extract of colocynth, one and a third grains; abstract of 
jalap and calomel, each one grain; gamboge, one-fourth of a grain. 
As there is soap in the first ingredient, the calomel is sooner or later 
reduced to the black oxide of mercury. 

The compound cathartic pills are a very efficient purgative, generally 
not producing much griping. They cause large watery stools, and are 


CATHARTICS. 


699 


used when it is desired to empty the bowels and deplete from the portal 
circulation. On account of the mercury in them, they should not be 
used as an habitual laxative. 

PODOPHYLLUM—PODOPHYLLUM. U.S. 

The rhizome of Podophyllum peltatum, or May-apple, a peren¬ 
nial herb, growing in the Northern and Middle United States. Podo¬ 
phyllum occurs in simple or branched, cylindrical, brownish pieces, 
about the thickness of a goose-quill, smooth or wrinkled longitudinally, 
often obscurely marked with the scars of leaf-scales, and furnished with 
numerous rootlets or their remnants attached to the lower surface. The 
taste is bitterish, acrid, nauseous. The rhizome contains the alkaloid 
Berberine , but the purgative power resides in two resins, one soluble, 
the other insoluble, in ether.* 

Physiological Action.— The experiments of Dr. Snow, of Dr. S. 
R. Percy (American Med. Times, vol. iv.), of Dr. F. E. Anstie (Med. 
Times and Gaz., March, 1863), and of others, have shown that, whether 
administered by the mouth or hypodermically, podophyllum produces 
in the lower animals purging, with colicky pains and sometimes vomit¬ 
ing. If the dose be sufficient, the stools are bloody, and after large 
amounts death occurs, preceded by hypercatharsis, prostration, and 
slight convulsions. On post-mortem examination, Dr. Anstie found in¬ 
tense inflammation, with ulceration of the mucous membrane of the 
small intestines. Upon man podophyllum acts as upon these animals, 
producing in large doses violent catharsis, accompanied by much pain, 
and is probably capable of acting as a fatal gastro-intestinal irritant. 
Ten grains produced in a strong woman violent bilious but not bloody 
vomiting and purging, with collapse, but final recovery ( Phila. Med. 
Times , xii. 520). The experiments already mentioned show that it acts 
by being absorbed, which is confirmed by the experience of Dr. Percy, 
who found that its application to an ulcer was followed by its specific 
effects. It has been claimed that it acts especially upon the liver; and 
much clinical testimony has been adduced to support this view, which 
is also confirmed by the experiments of Rutherford (see p. 669). 

Yery large doses are distinctly poisonous. A child four years old 
was killed in this city by an unknown amount. The symptoms were 


* Podowyssotzki states (Arch. /. Exper. Path. u. Pharm., xiii. 40) that he has isolated a 
crystalline substance ( Podophyllotoxin) which he believes to be the active part of podophyl- 
lin. One-tenth of a grain of it in a cat produced fatal vomiting and purging. By the action 
of an alkali it is resolved into two substances, pikropodophyllin and podophyllinic acid, which 
also exist in the rhizome. Pikropodophyllin resembles podophyllotoxin in its action upon the 
organism, but is less powerful. Dr. D. 0. Brau has used podophyllotoxin as a purgative for 
children, and finds it to represent podophyllin completely. To a child thirteen years old he 
gives from six- to nine-hundredths of a grain (Arch. f. Kinderheilk., ii., 1880). Podophyllo¬ 
toxin has been employed hypodermically by Drs. Dudley and Castle (Med. News, 1886, vol. 
ii. p. 509). One-tenth of a grain dissolved in alcohol produced local irritation, and in only 
one case out of four had any decided influence upon the bowels. 



700 


LOCAL REMEDIES. 


repeated vomiting, slight purging, collapse, and finally coma, ending in 
epileptiform convulsions (Dr. T. G. Morton). An infant twenty-two 
months old recovered from four grains ( Australasian Med. Gaz., ii. 237). 

Therapeutics. —Podophyllum is a powerful purgative, which usually 
requires ten or more hours to act, and produces “ bilious discharges” 
with griping pains. In this country it is very largely used in cases 
of acute constipation , and with very good effect; it has also been com¬ 
mended very highly by numerous practitioners in the so-called “ bilious 
attacks .” Owing to the extreme slowness of its action, it is not well 
adapted for combination with brisker cathartics. The same quality 
fits it, however, for use with calomel, it requiring nearly the same 
length of time as that drug to produce purgation. L. Lewis (Brit. 
Med. Journ ., 1876, ii. 546) affirms that in small repeated doses (gr. 
^ t. d.) it is a powerful stimulant of the gustatory nerves. 

Administration.— Although an extract (Extractum Podophylli ) is 
officinal, podophyllum is scarcely ever given in any other form than 
that of the resin, commonly known as Podophyllin. Resina Podophylli 
(U.S.) is prepared by precipitating a concentrated tincture with water: 
as berberine is soluble in the latter menstruum, the resin as thus ob¬ 
tained is free from the alkaloid. The portion of this duplex resin 
which is soluble in ether is certainly more actively purgative than the 
other part, to which, indeed, any purgative property is denied by some. 
Dose, as a purgative, from one-sixth to one-fourth of a grain; as a 
laxative, one-twelfth of a grain. 

ELATERIUM. 

A substance deposited by the juice of the fruit of Momordica Ela¬ 
terium,* or squirting cucumber, a native of Greece, but cultivated in 
England. In the interior of the ovate fruit is an elastic sac, which con¬ 
tains the seeds, and at ripening becomes so distended with juice that 
when the fruit falls off the vine, and the support is removed from the 
stem end, a rupture occurs at the latter position, and the liquid with 
the seeds is forcibly projected. The medicinal principle is said to be 
contained only in this inner juice. In order to avoid loss, the fruit is 
picked with a piece of the stalk adherent to it before ripening, and is 
opened by slicing. Elaterium occurs in light, friable, slightly incurved, 
greenish-gray cakes about a line thick. The taste is acrid and bitter; 
the fracture finely granular. Owing to the variability of commercial 
elaterium, the U.S. Pharmacopoeia now recognizes only the active prin¬ 
ciple, Elaterin (Elaterinum, U.S.), which was first separated in a pure 
state by Morries (Repertor. fur Pharm., xxxix. 134). It crystallizes in 
colorless, shining, rhombic, six-sided, odorless tables, of a very bitter 


* In Brazil the fruit of the Momordica bucha is used in dropsy, and appears to be a vio¬ 
lent hydragogue cathartic, causing both diarrhoea and vomiting when given by the stomach, 
and vomiting only when given, as it usually is in Brazil, by injection. See Loud. Med. Rec., 
815, 1887). 



CATHARTICS. 


701 


sharp taste and neutral reaction. According to Dr. H. Kohler ( Vir¬ 
chow's Archiv, Bd. 1. p. 287), it is insoluble in water and in glycerin, 
readily soluble in cold alcohol, and soluble with difficulty in ether and 
in turpentine.* 

Physiological Action. —Locally applied, elaterium is a very de¬ 
cided irritant, producing, according to Pereira, ulcerations in the fingers 
of those who handle the fruit and prepare the drug for market. When 
taken internally, it acts on man as a most powerful hydragogue cathar¬ 
tic, producing, when the dose and administration are properly regulated, 
enormous watery stools, without much irritation. On the lower animals 
its action is much less certain. Viborg asserts that a horse was unaf¬ 
fected by a pound of elaterium fruit; and I have given one and even 
two grains of a presumably active elaterium to a dog without pro¬ 
ducing very obvious results. If the dose be sufficiently large, all ani¬ 
mals probably are, however, fatally affected by elaterium, perishing by 
progressive depression. Professor Stille asserts ( Therapeutics , vol. ii. 
p. 459) that the death is not rarely preceded by violent vomiting and 
purging; and even when these are absent during life, post-mortem ex¬ 
amination reveals congestion and inflammation of the gastric and intes¬ 
tinal mucous membranes. In none of my own experiments, which have 
not been very numerous, has any purging been present; further, in 
Dr. Kdhler’s elaborate investigation (loc. cit.), elaterium dissolved in 
alcohol was injected under the skin, the powdered elaterium was put 
into the rectum, and was given by the mouth after the gall-duct had 
been tied so as to prevent the flow of bile into the intestine, and in 
neither case was there any purging, but prostration, apathy, disturbed 
respiration, salivation, and violent convulsions, ending in death. From 
these experiments Dr. Kohler draws the conclusion that elaterium ex¬ 
erts a general action upon the system, for which its introduction into 
the blood is all that is requisite, and also a purgative influence, for 
which it is necessary that there be bile in the duodenum to dissolve 
the elaterium and cause it to act locally on the intestine. The objection 
to this conclusion is that our present light seems to indicate that ela¬ 
terium does not purge dogs and rabbits, even when given by the mouth. 
Further, elaterium applied externally will cause purging in man (see 
Stille, Therapeutics, vol. ii. p. 459). So that the application of the con¬ 
clusions arrived at by Kdhler to man is incorrect. Kohler’s experi¬ 
ments proved that in animals elaterium is absorbed, even when given 
by the mouth, since he found it in the urine of the poisoned dogs and 
rabbits. 

Therapeutics. —Elaterium is certainly the most efficient of all the 
hydragogue cathartics, producing in properly-regulated doses the freest 
evacuations with comparatively little pain and irritation. It is there- 


* For the behavior of elaterin with various reagents, and for the methods of searching for 
it in medico-legal investigations, the reader is referred to Dr. Kohler's memoir. 



702 


LOCAL REMEDIES. 


fore indicated whenever a powerful cathartic of such nature is indi¬ 
cated. It is the most efficient of all the medicines of the class in 
general dropsy or in ascites. As, however, its action is very exhausting, 
great care should be exercised not to give it in too large doses, and also 
to support the strength of the patient during the period of purgation, 
and afterwards, by alcoholic stimulants, easily-digested nutritious food, 
and appropriate hygienic measures. In the latter stages of dropsy the 
injudicious use of elaterium may favor, and no doubt has accelerated, 
the fatal result, by intensifying the exhaustion. An idea has prevailed 
that elaterium is especially valuable in urcemia, because it pi'oduces an 
elimination of the urea in the stools; but I have been unable to find 
authority for the asserted elimination. Be this as it may, however, 
clinical experience has demonstrated the utility of elaterium in chronic 
renal disease. In order to deplete, elaterium has been employed in 
various diseases; but this use is not to be encouraged, and especially 
when there is any gastro-intestinal irritation or inflammation are the 
salines much preferable to elaterium. In cases of plethora, however, 
when there is a sudden determination of blood to the head and a very 
powerful impression is needed, the vegetable cathartic may be advan¬ 
tageously employed. 

Toxicology.— Elaterium is without doubt capable of destroying 
life, and that, too, when not in large quantity. I know of but one 
recorded death,—that of a woman who took, by the advice of a quack, 
two and two-fifths grains of the extract of elaterium and sixteen grains 
of rhubarb. Violent and uncontrollable vomiting and purging came 
on, and proved fatal in thirty-six hours. After death, the gastro-intes¬ 
tinal mucous membrane showed marked evidences of inflammation. 
(See Beck's Medical Jurisprudence , 12th ed., vol. ii. p. 719.) 

Administration. —It is not safe to commence with more than one- 
sixth of a grain of elaterium, to which should be united a grain of the 
extract of hyoscyamus and a drop of some aromatic oil. The dose 
of the officinal elaterin is one-twentieth of a grain; of the trituration 
(Trituratio Elaterini —1 to 10, U.S.), half a grain. Elaterium when 
injected hypodermically produces free purgation; but this method of 
administration is not justifiable, on account of the excessively severe 
local irritation, which has been the cause of fatal tetanus (case, Therap. 
Gaz., vol. ii. p. 27). 

CAMBOGIA—GAMBOGE. U.S. 

A gum resin, obtained in Siam by breaking off the leaves and young 
shoots of the tree known by botanists as Garcinia Morelia, and catch¬ 
ing in suitable vessels the juice as it drops. When the receptacles 
consist of hollow bamboos, the juice hardens into cylindrical casts, 
striated externally, and with a central cavity due to the loss of sub¬ 
stance in drying. This is the so-called pipe gamboge. Gamboge in sorts 
occurs in irregular masses. Gamboge is a hard, resinoid substance, 


CATHARTICS. 


703 


of a brittle, often conchoidal fracture, of a deep reddish-orange color 
on exposed surfaces, more yellowish when freshly broken, affording a 
bright-yellow powder, insoluble in water, with which it forms, how¬ 
ever, an intensely yellow emulsion. It has little or no taste, but when 
chewed produces, after a time, an acrid sensation in the fauces. It 
contains, according to Christison, as much as seventy-two per cent, of 
gambogic acid, a resinous acid of a cherry-red color, forming red salts 
with alkalies. This would appear, however, to be only one of the pur¬ 
gative principles of the drug, since it is less drastic than an equal 
weight of gamboge (Christison, Ann. Chem. Pharm. xxiii. 185; Pabo, 
Additam. quced. ad Virtutes, etc., Dorpat, 1851; Daraszkiewicz, Melete- 
mata de Besinarurn , etc., Dorpat, 1858): five grains of it produced in 
some persons only watery evacuations, in others not even these, and as 
much as seventeen grains have been taken without more serious effect 
than severe purgation. 

Physiological Action.— Administered by the mouth to dogs, cats, 
horses, and probably other of the lower animals, gamboge acts very 
generally as a violent drastic cathartic; but from the experiments of 
Schaur and of Orfila it would appear to cause sometimes simply vomit¬ 
ing, and, when in very large amounts, death, without any marked 
symptoms other than those of progressive depression. In such cases 
the gastro-intestinal mucous membrane was found highly inflamed, and 
the intensity of the irritation probably paralyzed the intestinal func¬ 
tions. According to Daraszkiewicz and to Schaur, in order for gam¬ 
bogic acid to act as a purgative the presence of bile in the intestine is 
necessary. As it has been determined by Schaur (quoted by Huse- 
mann, p. 754) that the hj’podermic administration of gamboge to dogs 
results simply in the production of local abscesses, and as A. L. Bichter 
asserts that when applied to raw surfaces in man it acts merely as a 
local irritant, it would appear that gamboge does not act by absorp¬ 
tion, and the alkaline juices of the alimentary canal probably dissolve 
it so that it can readily be taken up by the villi. Nevertheless, both 
Gmelin and Tiedemann assert that they have found its principles in 
the urine. Schaur has, however, been unable to detect it in the urine 
of persons or of animals taking it. Even when he injected large quan¬ 
tities of it into the blood of dogs he failed to find it in the urine, 
although he did obtain a resinoid substance which he believes to be a 
derivative of gambogic acid. Lewis, Abeille, and Ferriar assert that, 
when given in certain ways, gamboge acts as a decided diuretic. If 
this be true, absorption of it must occur. 

Therapeutics. —On account of the intense irritation which large 
doses of it produce, gamboge is very rarely, if ever, used alone as a 
purgative, but is employed to give sharpness to purgative combinations. 
In very obstinate habitual constipation it has been used in doses of one 
or two grains as a decided laxative. Its use as a hydragogue in dropsy 
is to be absolutely condemned, it being much less effective for this pur- 


704 


LOCAL REMEDIES. 


pose, and more irritating, than various other substances. The dose of 
gamboge is from two to five grains, made into pill with soap, or given 
in alkaline solution. 

OLEUM TIGLII—CROTON OIL. U.S. 

The fixed oil obtained from the seeds of Croton Tiglium, a euphor- 
biaceous shrub of Hindostan and other jDortions of Southern Asia. 
This oil is quite viscid, varies in color from a pale yellow to a dark 
reddish brown, and has an acid reaction. Its taste is hot, acrid, and 
extremely persistent; its odor faint, but peculiar. The composition 
of croton oil is very complex, and the active purgative principle has 
not as yet been separated. The most important of the substances so 
far discovered in the drug is that found by T. Schlippe and named by 
him Crotonol. According to this investigator, it is not the purgative 
principle, although to it the drug owes its power of causing a peculiar 
dermal inflammation. 

Physiological Action.— Locally applied, croton oil is an intense 
irritant, producing upon the skin an eruption which is at first papular 
but in a very short time becomes pustular. This effect of the drug will 
be considered more in detail under the heading of Counter-Irritants. 
When given by the mouth, croton oil affects the horse, the dog, and prob¬ 
ably other mammals, as it does man, producing violent purging, with 
severe griping, and, when in sufficient amount, fatal gastro-intestinal 
inflammation. The question as to whether it acts by producing a 
simple local impression or by absorption is unsettled. In the experi¬ 
ments of Hertwig (Stille, Therapeutics , 2d ed., vol. ii. p. 449) and of 
Bucheim ( Virchow's Archiv, xii. 1), purgation did not follow the injec¬ 
tion of the oil into the veins of animals; but Conwell obtained a result 
contrary to this, and there is considerable testimony that its external 
use in man is sometimes followed by purging (Stille, Therap., 2d ed., 
vol. ii. p. 451). The probabilities seem to be in favor of the purgation 
being at least in part due to absorption of the oil. 

Therapeutics.— Croton oil is a very rapidly acting, violent drastic 
and hydragogue cathartic. It is chiefly used in cases of obstinate con¬ 
stipation from disease of the nervous system or from lead-poisoning. 
The fact that a drop of it placed upon the tongue will purge actively 
peculiarly fits it for use in mania, delirium tremens , and other diseases 
when the patient refuses to take medicine. When it is desired, as in 
some brain-diseases, to revulse through the bowels, croton oil is prob¬ 
ably the most available of the cathartics. The dose is one drop, which 
may be administered in pill, in emulsion, or by simply placing it upon 
the tongue. In overdoses, croton oil is a violent poison. 

Toxicology.— Although in small amounts croton oil causes such 
severe symptoms, yet in larger quantities it has failed to produce as 
serious results as would be naturally expected. It is, however, very 
possible that in at least some of these recorded cases the oil was adul- 


CATHARTICS. 


705 


terated. Cowan has reported a case (Husemann, Toxicologie, Bd. ii. p. 
443) of a child, four years old, who recovered in two days from a tea¬ 
spoonful of croton oil taken on a full stomach; Adams (Ibid.) saw re¬ 
covery in an adult after the ingestion of a drachm; and in the Boston 
Med. and Surg. Journ., 1S68, i. 294, is recorded the case of a woman 
who took about an ounce, was vomited forty-five minutes afterwards 
with mustard, and finally recovered. The minimum fatal dose is not 
known, and probably varies greatly. A child aged thirteen months 
was killed by a quantity believed not to exceed three minims (Med. 
Times and Gaz., 1870, i.). Giacomini (Stille, Therapeutics, vol. ii. p. 451) 
reports a case in which twenty-four grains of the drug proved fatal in 
as many hours: although there were but four stools, the patient pre¬ 
sented the symptoms of general collapse, preserving consciousness to 
the last. A little less than two drachms has caused vomiting and death 
without purging (Amer. Journ. Med. Sci., April, 1874).* 

Helleborus Niger.— Black hellebore is the root-stock of Hellebo- 
rus niger, a native of Southern and Middle Europe. It contains two 
active medicinal principles, Helleborein and Helleborin. Both of these 
substances are glucosides. According to Marme (quoted by Huse¬ 
mann), helleborein is an active cardiac poison and a drastic purgative, 
while helleborin, although having to some extent the latter property, 
acts chiefly as a narcotic, producing in animals at first inquietude, soon 
followed by paresis both of motion and of sensation, constantly deep¬ 
ening after large doses into death. 

Black hellebore when taken by man is said to cause, if in sufficient 
quantity, violent catharsis, with vomiting, abdominal pains, cramps, 
and convulsions, which have ended fatally. Locally applied, the fresh 
root is a violent irritant. It has been used in times past as a hydra- 
gogue cathartic, but appears to be both uncertain and very harsh in 
its action, and, in this country at least, is never used at present. The 
extract and the tincture are purgative in doses of ten grains and two 
fluidrachms respectively. 


* For other cases, see Med. Gaz., vol. xliii.; Edinb. Med. Journ., 1861; Lancet, 1870, i.; 
Brit. Med. Journ., 1874, i.; Ann. d’Hyg., 1871, i. 


45 



FAMILY IV-DIURETICS. 


Diuretics are medicines used for the purpose of increasing the flow 
of urine. Some of them, without doubt, act directly upon the secreting 
structure of the glands, but others of them induce the increased secre¬ 
tion indirectly, by, in some way, removing the obstacle to secretion. 
It is notorious that diuretics often fail in practice when their action 
is most urgently needed. This results, in many cases, from the nature 
of the disease, and is not because diuretics are powerless or uncertain. 
Thus, in cardiac disease the congestion of the kidneys may be so great 
as to render secretion impossible; and it is equally evident that when 
the tubules are destroyed by Bright’s disease medicines must be power¬ 
less to provoke excretion. 

There are certain agencies whose influence upon the kidneys should 
never be lost sight of in exhibiting diuretics. Thus, cold, by checking 
the secretion of the skin, often acts as a most efficient remedy of the 
class. Again, mere vascular fulness tends to provoke excretion of water 
by the kidneys. This assertion does not rest simply upon theory. In 
an elaborate series of experiments, E. Roux ( Archives Physiol ., 1874, 
p. 578) found that the ingestion of large quantities of water greatly 
increased the flow of urine, but did not sensibly affect the elimination 
of urea or uric acid, although the elimination of the chlorides seemed 
to be augmented; in Bocker’s experiments, however ( Brit . and For. 
Med.-Chir. Rev., xiv., 1854), large draughts of water increased not 
only the amount but also the solids of the urine. The investigations 
of J. Meyer (. Hoffmann und Schwalbe's Jahresb., 1881, 345) explain these 
discrepancies and show how water may be of service in various diseases. 
He found that at times, when the tissues were full of the products of 
disintegration, the effect of water in increasing elimination was very 
marked, but that upon the wasting processes of the body the water 
exerted no influence. It would seem, therefore, that while we cannot 
by water produce tissue-disintegration, we can by it wash out the re¬ 
tained products of tissue-change; and I cannot help suspecting that the 
great rarity of uninherited gout in America has some connection with 
the universal habit of drinking water very freely. The taking of large 
draughts of simple water at regular intervals has been found to act 
very favorably in acute Bright's disease , greatly increasing the urinary 
flow, and at the same time lessening the irritation of the kidneys. In 
various inflammations or irritations of the genito-urinary organs, as in 
706 



DIURETICS. 


707 


gravel, whenever it is desired to make the secretion less irritating or 
less concentrated, the value of water as an adjuvant to medicinal diu¬ 
retics should always be taken advantage of. 

There certainly is a very marked antagonism between the bowels 
and the kidneys, so that free catharsis reduces very decidedly the se¬ 
cretion of urine. There is also an antagonistic relation between the 
skin and the kidneys, so that an increase in the excretion from one of 
these generally results in a diminution of that of the other emunctory. 
This should also be taken advantage of when a diuretic action is desired. 
Sweating and purging at such times are therefore to be avoided. When 
a diuretic is exhibited, the patient should be kept cool, walking about 
if able, or if it is necessary for him to remain in bed he should be 
covered lightly. Not rarely, a remedy which when administered cold 
and the patient kept cool afterwards will act as a diuretic, will when 
it is given hot and the patient kept warm act as a diaphoretic. 

There are various substances which are of such nature that when 
eliminated by the kidneys they act upon the mucous membrane of the 
bladder and other surfaces over which they pass. It seems hardly cor¬ 
rect to speak of these drugs as diuretics; yet they are best considered 
in the present class. 

The chief indications for the use of diuretics are as follows: 

1. To maintain the action of the kidneys. It is hardly necessary here 
to discuss the necessity of excretion to the system. In various kidney- 
diseases this indication is very urgent; but as the lessened excretion 
too often depends upon a profound organic alteration of the renal 
secreting structui*e, it is evident that very frequently diuretics must 
fail when most needed. In the great majority of cases in which diu¬ 
retics are used to fulfil the present indication, only the mildest of the 
class should be employed. Whenever there is inflammation of the 
kidneys, even if it be chronic, irritating diuretics should be avoided. 
When lessened urinary excretion is purely functional in its origin, 
diuretics are often most serviceable. In fevers especially is it neces¬ 
sary to maintain the action of the kidneys; for this purpose water 
should always be freely given during fever. The alkaline diuretics 
sometimes may be exhibited; but the most generally serviceable of all 
remedies of the class in the febrile state is the sweet spirit of niti'e. 

2. To evacuate fluid. For this purpose diuretics are employed in all 
forms of dropsy, and are successful in direct proportion to the univer¬ 
sality of the effusion and the structural perfection of the kidneys. 

3. To soothe and diminish irritation of the genito-urinary organs. The 
value of water in fulfilling this and the next indication has already 
been pointed out. By lessening the acidity of the urine and rendering 
soluble the uric acid which is present, the alkalies are equally impor¬ 
tant in carrying out the present and the following indication. 

4. To alter the urinary secretion so as to prevent the deposition of calcu¬ 
lous material. Notwithstanding it has been claimed otherwise, I think 


708 


LOCAL REMEDIES. 


it indubitable that as yet no practical measure has been devised of dis¬ 
solving a calculus when once formed. Even to alter the urine so as to 
prevent further deposition is probably impracticable, except in cases of 
uric acid or phosphatic diathesis. A discussion of the use of diuretics 
for this purpose will be fouud in the article on Potash, which is the 
only diuretic used to meet the present indication. 

Diuretics are very naturally divisible into three sets,—the hydra- 
gogue diuretics, the refrigerant diuretics, and the alterative diuretics. 
These classes, of course, grade more or less into one another, but they 
are sufficiently distinct for practical purposes. The drugs belonging to 
the first set simply increase the flow of water from the kidneys, and 
are therefore used chiefly for the relief of dropsy; those of the second 
division exert a marked sedative action upon the system, and gener¬ 
ally do not increase to a great extent the water of the urine, but modify 
the secretion in one way or the other, and are mostly given to render 
the urine less irritant or for their sedative and eliminative action in 
acute disease. Diuretics belonging to the third division are of such 
nature that their active principles are eliminated by the kidneys and 
act upon the mucous surfaces over which they pass,—for which purpose 
they are chiefly employed. 

HYDRAGOGUE DIURETICS. 

SCILLA—SQUILL. U.S. 

The bulb of Scilla maritima, a liliaceous plant growing in the south 
of Europe, especially on the shores of the Mediterranean. The bulb 
varies in size from that of a child’s head to that of the fist. It is com¬ 
posed of numerous layers or scales, which separate when it is sliced for 
drying. As kept in the shops, squill is in horny flakes, of a white or 
red color, becoming leathery when wet, and having an acrid bitter taste. 
It yields to water and alcohol, and also to vinegar. Scillitin has been 
asserted to be the active principle of squill; but the scillitin of different 
authors is diverse. According to Keil, there are two active principles 
in squill, one of which he names Scillitin , representing the diuretic and 
expectorant properties of the drug, while the toxic and irritant prop¬ 
erties reside in a substance which he calls Sculein; recently ( Arch.f . 
Exper. Path. u. Pharm., xi. 22) C. V. Jarmersted* has described a new 
principle from squill ( Scillain ), and Merck has sold three substances as 
derived from squill,— Scillin, Scillipicrin, and Scillitoxin.f 


* Jarmersted states that his scillain increases, and afterwards diminishes, blood-pressure, 
causing vomiting and purging, and finally paralyzes the heart-muscle. 

f Dr. Fronmiiller has reported ( Memorabilien , 1879, xxiv. 250) a series of experiments 
made, upon persons suffering from various ailments, with the scillin, scillipicrin, and scilli- 
toxin of Merck. He found that scillitoxin in doses of 0.45 grain acted as a rather uncertain 
diuretic, and frequently caused giddiness, headache, and loss of appetite; scillin seemed 



DIURETICS. 


709 


Physiological Action.— -According to the experiments of Chateau 
(quoted by Stille) and of Marais, squill in poisonous dose produces in 
dogs and other of the lower animals vomiting, then purging, dulness, 
stupor, intermittent paralysis, convulsions, and finally death in the 
course of twelve or fifteen hours. The temperature always falls. 
Professor Schroff ( Wochenblatt der Zeitschr. der k. k. Gesellsch. zu Wien , 
1864, p. 424) has reinvestigated this subject, using alcoholic extracts 
of the red and white squill, and also the scillitin of Merck. Fifteen 
grains of the latter caused in a vigorous rabbit great weakness, mydri¬ 
asis, and, after an hour or so, tremors gradually becoming violent, par¬ 
tial stupor, labored breathing, and finally death; twenty-three grains 
caused in another rabbit sinking of the pulse- and respiration-rate, 
mydriasis, diuresis, and death, preceded by the other symptoms noted 
in the previous case. The alcoholic extract (fifteen grains) caused (loc. 
cit., 424) in a large rabbit decrease of the number of respirations per 
minute, with rise of the pulse-rate, narrowing of the pupil, semi¬ 
stupor, and finally death. On post-mortem examination of rabbits 
killed with the scillitin, erosion of the gastric mucous membrane, 
pericardial and sub-pleural hemorrhages, pulmonary apoplexy, bloody 
urine, and hypersemia of the kidney and brain were found. In rab¬ 
bits destroyed by the extract, gastric erosion and the various hemor¬ 
rhages were wanting. It seems evident that the scillitin of Merck 
does not represent squill. In a memoir, which I have seen only in 
abstract, Dr. Husemann states that the extract of squill has no expec¬ 
torant properties, that it acts on the heart like digitalin, that its diuretic 
powers are dependent upon its action on the circulation, and that both 
in large and in small doses it uniformly produces a rise of temperature 
(.Deutsche Med. Wochens ., No. 13, 1875; abstracted Lond. Med. Rec., 
1876, p. 120). Husemann also finds commercial scillitin very uncer¬ 
tain. These statements receive confirmation, at least in part, from the 
researches of C. Lupinski, who has found that scillitoxin is a powerful 
stimulant to the peripheral vagi in the frog, causing slowing of the 
pulse, and in certain doses diastolic cardiac arrest, and in the dog 
slowing of the heart. Large doses cause in the frog tetanic contrac¬ 
tions of the heart. He also found that in the dog large doses finally 
paralyze the peripheral vagi and produce a rapid pulse. The arterial 
pressure is increased, partly, it is affirmed, by the increased cardiac 
energy, and partly by a peripherally-produced vaso-motor contraction 
(.Hoffmann und Schwalbe's Jahresb., 1883, 123 ; from the Russian). 

Clinical experience has established the fact that in small repeated 
doses squill is diuretic as well as expectorant. The remedy is evidently 
a stimulant to the kidneys, and in ovei’doses causes an irritation whoso 


to be devoid of diuretic properties; while a gramme of a solution of scillipicrin in water 
• (one part in fifty) administered hypodermically usually caused a great flow of urine, without 
other evil symptoms than some smarting at the place of injection. 



710 


LOCAL REMEDIES. 


result is lessening of the secretion, scanty bloody urine, or absolute sup¬ 
pression of urine, according to the ingested dose of the poison. Its 
diuretic action has been noted in animals by Schroff and by Chiarenti 
(quoted by Stille), and there can be no doubt as to the power that squill 
has of increasing the watery portion of the urine. I know of no studies 
upon its action on the urinary solids. 

That the active principles of squill are absorbed is proved not only 
by its action on the kidneys, but also by the fact that its characteristic 
effects on the system have been seen to follow its external application. 
(See Stille, Therapeutics , 2d ed., vol. ii. p. 534.) 

Therapeutics. —As a diuretic, squill is in great repute, and is espe¬ 
cially employed in cases of dropsy where the condition of the system 
is atonic and where there is no disease of the kidney. Professors Geo. 
B. Wood and Chapman recommend it very strongly in eases of serous 
effusion into the pleura or the pericardium dependent upon chronic in¬ 
flammation of the membrane. In these cases it may often be advan¬ 
tageously combined with calomel. The combination of squill and digi¬ 
talis is very efficient in cardiac dropsy. The one contra-indication to 
the use of squill is the existence of any form of Bright’s disease or of 
acute irritation of the kidney. 

Toxicology. —Overdoses of squill produce violent purging and vom¬ 
iting, with abdominal pain, lessened or almost suppressed secretion of 
bloody, albuminous urine, and very marked reduction of the pulse-rate, 
ending, it may be, in collapse, convulsions, and death. According to 
Husemann ( Toxicologie , Bd. i. p. 413), twenty-four grains of it have 
brought about a fatal result. The treatment consists in the evacuation 
of the stomach and bowels by ipecacuanha and castor oil, if nature 
has not already fulfilled the indication; the free use of opium; the ex¬ 
hibition of large quantities of water, for its action on the kidneys ; and 
the usual measures for the relief of gastro-enteritis, if much tender¬ 
ness be present. Early in the poisoning care should be exercised in the 
exhibition of alcoholic stimulants, for fear of increasing the gastric 
irritation; during the stage of collapse they may be imperatively de¬ 
manded, and with their use should be combined that of dry heat 
applied externally, and of the other usual measures of relief during 
collapse. 

Administration. —As a diuretic, squill should be given in solid 
form, two grains every two hours, the dose being gradually increased 
until some nausea is felt. The preparations of squill are the tincture 
(Tinctura Scillce, —1 to 6.6, U.S.),—dose, nj;x to njjxx; the vinegar 
(.Acetum Scillce —1 to 10, U.S.),—dose, njjx to ngxx; the syrup ( Syrupus 
Scillce , U.S.),—dose, fjss to fji; the fluid extract ( Extractum Scillce 
Eluiclum, U.S.),—dose, njji to njjiii. 

Digitalis, in its general relations, has already been sufficiently dis¬ 
cussed, and it remains only to speak of its employment as a diuretic. 


DIURETICS. 


711 


In the first place, it should be distinctly understood that it has no 
alterative effect whatever, either upon the nature of the secretion or 
upon the mucous membrane over which that secretion flows. In other 
words, when it has any effect it is purely a hydragogue diuretic, simply 
increasing the watery portion of the urine. That digitalis has direct 
diuretic properties cannot, I think, be doubted. Nor does it seem less 
certain that it varies greatly in their exercise, so that when given to 
persons in health it will sometimes produce free diuresis and will at 
other times fail to do so. Another point to be constantly borne in 
mind during its administration is the fact that, like all the other effects 
of digitalis, diuresis is very slowly induced, and is very persistent when 
produced by the ordinary cautious method of administration. The 
diuresis of digitalis is not simply a result of its action on the circula¬ 
tion, since it will sometimes appear before the circulation is sensibly 
affected. At the same time, it is very evident that in disease the good 
effect of digitalis upon the renal organs is often in large measure due 
to its action upon the heart. Thus, in dropsy from a dilated heart the 
renal gland-cells cannot secrete because they are not supplied with the 
proper kind and quantity of blood, their circulation, like that of the 
remainder of the body, being nearly stagnant. If under these circum¬ 
stances digitalis be exhibited, and the circulation becomes compara¬ 
tively free and active, the resultant diuresis is wrought out through a 
double mechanism, partly indirectly and partly directly produced by 
the drug. As a consequence of these facts, the clinicians have long 
since practically determined that digitalis is especially valuable as 
a diuretic in cardiac dropsy. Digitalis is also very useful in renal 
dropsy , both in the subacute and in the chronic form. Of course, like 
everything else, it frequently fails in these varieties of Bright’s disease, 
but certainly it should always be tried. Professor George B. Wood 
asserts that he has seen cases of “ what appeared to be decided and 
obstinate attacks of Bright’s disease, with universal dropsy, and uncon¬ 
nected with scarlatina, which yielded completely and permanently to 
the use of digitalis.” In acute suppression of urine, digitalis is often a 
very valuable remedy when applied externally, especially when the 
stomach refuses to retain medicines. At the same time, it should be 
remembered that large doses of the drug used in this way sometimes 
induce very alarming symptoms. Flannels saturated with the tincture 
may be applied to the abdomen, or poultices of the leaves may be 
similarly used. Dr. Lente ( Psychol. and Med.-Leg. Journ., 1875) says 
that he has been accustomed to use, even in children, four ounces of 
the best English leaves, and with a quart of water “make a poultice 
which extends all round the body, and from the thorax to the pelvis.” 
Only in desperate cases is such heroic use of the remedy warrantable. 
Dr. E. F. Fannell has seen {Brit. Med. Journ., March 11, 1871) almost 
fatal collapse produced by the external use of an ounce of the tincture 
in a case of renal dropsy. 


712 


LOCAL REMEDIES. 


Administration. —The dose of the powder of digitalis, as a diuretic, 
is three grains a day (in divided doses), increased by a grain every 
second or third day, until some sensible effects are manifested. The 
infusion or the tincture may be substituted for the powder, in corre¬ 
sponding dose. Digitalis, in the majority of cases, is best given in 
combination: in cardiac dropsy it is much more efficient if given with 
squill; in renal diseases the bitartrate of potassium may be exhibited 
simultaneously. While our present knowledge of the physiological 
action of digitalis is in accord with the ascertained clinical fact that 
it is safe to give the drug cautiously in the last stages of cardiac ex¬ 
haustion, yet it should never be forgotten that, as a diuretic, digitalis 
sometimes refuses to act, and that it is possible to produce the most 
profound depression with it without inducing the desired result. It is, 
therefore, worse than useless to persist with the medicine to the danger 
of the patient after its constitutional effects have been distinctly pro¬ 
duced and no diuresis has occurred. The diuretic external use of digi¬ 
talis is made by putting a poultice of an ounce of the fresh leaves upon 
the abdomen of the patient, or, preferably, flannel cloths wrung out 
of the infusion may be applied to the same part and covered with oiled 
silk, or half an ounce to an ounce of the tincture may be sprinkled 
upon previously-moistened spongiopilin. In either case the applica¬ 
tion should not be allowed to stay on for more than eight hours, at the 
expiration of which period it should be removed, to be replaced at the 
end of six hours if no effect has been produced. 

SCOPARIUS—BROOM. U.S. 

Scoparius is the dry tops of Cytisus Scoparius, or the common broom- 
plant of Europe, which is cultivated in this country and has in some 
places escaped from the gardens. It occurs as greenish twigs, with 
minute downy leaves, has a bitter nauseous taste, and, when bruised, a 
peculiar odor, and yields its virtues to hot water. Dr. Stenhouse dis¬ 
covered in scoparius a neutral crystallizable principle, Scoparin, whose 
physiological and therapeutic action has not been sufficiently investi¬ 
gated in order for us to arrive at a positive conclusion, but which ap¬ 
pears to represent the purgative and diuretic influences of the drug; 
also a liquid alkaloid, Sparteine , which has already been discussed under 
the head of Cardiac Stimulants. 

In very large doses, scoparius produces in man free purging, and 
even vomiting; but as ordinarily administered it is simply a most effi¬ 
cient hydragogue diuretic. It is much used in general dropsy , and is one 
of the most reliable remedies of the class, seldom failing unless the 
structural lesions are such as to prevent any diuretic from acting. It 
is best given in decoction,—half an ounce of the tops in a pint of water 
boiled down to half a pint. Of this an ounce may be given every three 
hours until some effect is produced; or a fluid extract, which is not 
officinal, may be given in half-drachm doses. 


DIURETICS. 


713 


Blatta.— The dried bodies of the Blatta orientalis, or cockroaches, 
have long been popularly used in Russia as a remedy for dropsy. Bogo- 
molow found in them a crystalline principle which he called Antihydro¬ 
pin.* Under their influence the sweat and urine are said to be greatly 
increased and the dropsy rapidly to disappear. When the urine con¬ 
tains albumen, this is greatly lessened or disappears entirely. The 
proper dose is uncertain. Bogomolow ( Lond. Med. Record , 1877, p. 502) 
gives four and a half grains three times a day to children. Probably 
lifteen to twenty grains daily is about the proper commencing dose for 
the adult. 

Spiritus aEtheris Nitrosi, U.S.— Sweet Spirit of Nitre will be con¬ 
sidered in the class Diaphoretics, in detail. Suffice it for the present 
to state that when given in a single large dose (a teaspoonful to a table- 
spoonful) and the patient afterwards kept cool, sweet spirit of nitre acts 
as a moderately efficient diuretic, increasing the watery portion of the 
urine, but not to such an extent as to render the drug available for use 
by itself in dropsy. It acts upon the kidneys as a mild, soothing 
stimulant, and is mostly employed as an adjuvant to more powerful 
diuretics, or by itself when there is simply diminished renal excretion 
of functional origin, or when the kidneys suffer from slight congestion, 
as shown by aching in the loins without other more serious symptoms. 

Caffeine is one of our most valuable diuretics. For an account of 
its properties, see Caffeina. It is also probable that pilocarpine is of 
great value as a diuretic. See Jaborandi. 

REFRIGERANT DIURETICS. 

POTASSIUM. (K.) 

The salts of potassium, like the substance itself, are very poisonous 
to the lower animals. According to Dr. Paul Guttmann, they are all 
exactly alike in the character and the intensity of their action; but 
further experimentation is wanting before this point can be considered 
as decided, and I have preferred to study the bromide entirely separate 
from its congeners. 

In the experiments of Podocaepow ( Virchow's Archiv , 1866, Bd. 
xxxv. p. 460) it was found that one cubic centimetre of a solution of 
the chloride (one to five), given to a frog by the stomach, would in 
eight minutes cause abolition both of voluntary and of reflex move- 


* J. Tschernischew ( Schmidt’s Jahrb., cxcvii. 205) states that he has found in the cock¬ 
roach a very powerful poison, Blattic acid , which produces in frogs paralysis of the heart 
and motor nervous system. In the mammal small doses slow the pulse without affect¬ 
ing the vagi, while large doses paralyze the vagi and increase the pulse-rate. The blood- 
pressure is reduced by a direct action upon the vaso-motor centre. The secretion of urine i3 
increased from five- to ninefold by even moderate doses. 



714 


LOCAL REMEDIES. 


ments. After from fifteen to twenty minutes, cardiac arrest occurred. 
Upon mammals similar results were obtained, but the abolition of mo¬ 
tility was apparently not so profound as in the frog. Thus, four or five 
drachms of the chloride of potassium injected into the stomach of the 
dog caused bloody stools, reduction of temperature, muscular weakness, 
and death without convulsions. Although in most, if not all, of the 
reported cases of poisoning by potash salts, the most prominent symp¬ 
toms are those due to the local action upon the alimentary canal, yet it 
would seem that poisonous doses act upon man as upon other mammals, 
as great feebleness of pulse and lowering of temperature have been 
noted as constant phenomena. 

Circulation .—The most marked action of the potash salts is upon 
the heart. "When a frog is killed by a salt of potash, the heart* is 
arrested in diastole, according to both Podocaepow f and Guttmann. 
The blood-current before death is greatly lessened in force, as was deter¬ 
mined by Podocaepow by watching the circulation in the web, and by 
comparative experiments in regard to the rate at which blood flowed 
from wounded vessels in poisoned and in unpoisoned frogs. In mam¬ 
mals, potash influences the heart even more markedly than in cold¬ 
blooded animals. Ten or fifteen grains of the chloride quickly injected 
into the jugular vein suffice to produce instant cardiac death. Accord¬ 
ing to Aubert and Dehn ( Pfluger's Archiv, 1874. p. 122), for a few 
seconds before complete suspension of movement there are irregular, 
“ stormy” convulsions, which run through the heart in a sort of peri¬ 
staltic manner with great rapidity, but have no effect in expelling the 
blood. A curious fact discovered by Aubert and Dehn is that the 
effect of the potash is not permanent unless it has continued a certain 
length of time. Thus, a hound received into its jugular a fatal dose 
of the chloride of potassium, and ten seconds after all pulsations had 
ceased the crural artery of a second dog was connected with the jugu¬ 
lar of the poisoned animal, when the heart recommenced its move¬ 
ments, only to cease again after a time. The action of a poisonous 
dose of potash upon the heart appears to be a local one. Traube found 
that when death in the dog was produced by injection into the jugular 
the heart-muscle failed entirely to respond to electricity. In this case, 
however, the heart received at once the full dose of the poison, and the 
careful experiments of Podocaepow and of Guttmann have shown that 
when the potash is introduced gradually and in the more ordinary 
methods into the circulation, the contractility of the cardiac muscle, 


* The poisonous influence of potash upon the heart was, I beliere, first discovered by 
Black ( Comptes-Rendus , 1839), and has been confirmed by Bouchardat (An nun I re de Thera- 
peutique, 1844), by Grandeau (Robin’s Journal de I’Anatomie, 1864), by Rabuteau (L’ Union 
Midicale, 1871), and by others. 

f Virchow’s Archiv, Bd. xxiii. It is proper to mention that Podocaepow states on p. 506 
that the arrest is sometimes systolic, sometimes diastolic, although on p. 511 he asserts that 
the arrest never occurs in systole. 



DIURETICS. 


715 


although very much impaired, is not at the time of death entirely 
destroyed; in frogs it is less affected than in warm-blooded animals. 
Guttmann has found that previous section of the vagi has no influence 
upon the action of large doses of potash, which therefore cause diastolic 
arrest by a direct impression upon the cardiac muscle. 

Although the effects of large doses of compounds of potassium on 
the heart appear to be made out, definite knowledge is still wanting 
in regard to small doses. Traube ( Gesammelte Beitrage , Bd. i. p. 386) 
asserts as the result of his experiments that, injected into the blood in 
doses of two or three grains, the nitrate of potassium produces a fall 
in the pulse and a rise in the arterial pressure. Aubert and Dehn 
(. Pfluger's Archiv, 1874, p. 126) have experimented with a number of 
the salts of potash, and found that, with the exception of the per¬ 
manganate, they all act upon the circulation in the manner just de¬ 
scribed. If larger doses of the potash preparations were employed, 
the rise was preceded by a temporary fall of pressure, and if the doses 
were still larger, the fall was permanent. The first fall of pressure, as 
well as the permanent impression produced by large doses, was prob¬ 
ably caused by the direct action of the drug upon the heart-muscle. 
The cause of the rise is still enveloped in obscurity, as is also the man¬ 
ner in which potash affects the pulse-rate. Traube affirms that if the 
vagi be cut after exhibition of the potash salt, the lessened pulse-rate 
instantly becomes rapid, and the already increased arterial pressure 
rises still further. The same observer also found that after section of 
the pneumogastrics small doses of the nitrate produced a fall in the 
pulse, with increased arterial pressure; but on a repetition of the dose 
in the same animal no lessening of the pulse-frequency was perceptible, 
while each time the pressure rose. This seems to indicate that the 
cardiac action of the drug is independent of the inhibitory apparatus, 
which is confirmed by the experiments of Aubert and Dehn ( loc. cit., p. 
145) upon atropinized dogs. It is very probable, but not in any way 
proved, that the rise of pressure is brought about through the vaso¬ 
motor nerves. Both Podocaepow (loc. cit., p. 515) and Aubert and 
Dehn (loc. cit., p. 150) have called attention to the very temporary 
effect of the potash injections: thus, after small doses the arterial press¬ 
ure returns to its normal position in three minutes; after large doses 
the maximum effect is reached in ten minutes. Aubert and Dehn also 
assert that there is no cumulative action, many small doses given at 
brief intervals leaving no residual effect; but this is in direct opposi¬ 
tion to the statements of Guttmann. Kdhler affirms that after section 
of the spinal cord potash salts have less influence upon the heart, and 
that larger doses are required to kill (Centralbl. f. Med.Wiss., 1877, p. 
675). The only fixed conclusion warranted by the evidence is the abso¬ 
lute necessity of further investigation. Mairet and Combemale assert 
that even after moderate doses of the nitrate of potassium changes can 
be seen in the red blood-corpuscles, which become granulated and some 


716 


LOCAL REMEDIES. 


of them larger than normal ( Comptes-Rendus Soc. de Biolog ., 1887, vol. 
iv. pp. 57 and 63). 

Muscular and Nervous Systems. —The action of the drug upon the 
motor system is more marked in cold- than in warm-blooded animals. 
Podocaepow believes, but does not definitely prove, the paralysis of 
both voluntary and reflex movement to be of muscular origin. The 
much more elaborate experiments of Guttmann show that the muscles 
of poisoned frogs are not only excitable at the time of death, but are 
nearly as sensitive as normal muscles, and maintain their excitability 
nearly as long after death. As both nerve-trunks and muscles are 
capable of performing their functions in the dying frog, Guttmann 
concludes that the paralysis is of spinal origin, a conclusion which he 
confirmed by tying the aorta directly above its bifurcation and then 
administering the potash, when the paralysis appeared as early in the 
protected hind legs as in the non-protected front ones. 

By an elaborate series of experiments, Drs. Binger and Murrell have 
shown that the potash salts, in sufficient concentration, act powerfully 
upon the cerebrum, the motor and sensory nerves, and the muscles; in 
a word, that they are poisonous to all the higher forms of tissue. In 
poisoning, however, the brain and spinal cord are paralyzed much more 
quickly and deeply than are the peripheral nervous and muscular tissues; 
consequently, in general poisoning the symptoms are produced through 
the higher nerve-centres (Journal of Physiology , i. 88). All of the potash 
salts probably act in a similar manner* as depressants of the spinal cord, 
their power, according to the experiments of Ringer and Morshead 
( Journ. Anat., xii. 82), being in direct proportion to the amount of 
potash they contain. 

General Influence. —Outside of the body, potash favors very greatly 
the oxidation of organic substances. Thus, when olein is exposed to 
ozone no change occurs, but if potash be added rapid oxidation follows. 
Again, when albumen or hsematin is dissolved in water no change, or a 
very slow one, occurs, but if potash be added the organic principle is 
oxidized with extraordinary rapidity. Whether a similar influence is 
or is not exerted within the body is not as yet completely determined, 
but the present evidence strongly indicates that it is.f The fall of tem¬ 
perature produced by poisonous doses of potash salts would seem to 
point to lessened oxidation, but is probably simply the result of the pro¬ 
found depression of the circulation. The chief arguments in favor of 
the theory of increased oxidation in the system as yet brought forward 
have been drawn from the studies of the action of the drug upon the 
urinary excretion in health and in disease. Potash and its salts admin- 


* Ringer and Murrell, applying the chlorides, iodides, and bromides of potassium and 
ammonium directly to the ends of the afferent nerves, found that they paralyzed, the effect 
of the potassium being muoh the most powerful and permanent, that of ammonium the next, 
and that of sodium the least (Journ. Anat., xii. 71). 

f Lehman was, I believe, the first to originate the oxidation theory. 



DIURETICS. 


717 


istered in sufficient quantity, under ordinary circumstances, not only 
increase the watery portion of the urine, but, as Professor E. A. Parkes 
and others have demonstrated, they do more. In an elaborate series 
of experiments upon himself, Professor Parkes found (Brit, and For. 
Med.-Chir. Bev., 1853, xi. 258) that liquor potass® (f 3ii) when taken 
fasting produced in from thirty to ninety minutes an increased flow of 
slightly acid urine containing the whole of the alkali and organic matter, 
which differed in quality from that ordinarily found in urine, and was 
also larger in amount than normal. An organic acid, certainly neither 
uric nor hippuric, was believed to form a part of the solid matter by 
Parkes, who attributes the alteration of the urinary solids to the oxi¬ 
dizing influence of the potash. Taken after meals, the liquor potass® 
acted simply as an antacid, and had no perceptible effect upon the urine. 
Both the acetate and the nitrate of potassium in Parkes’s experiments 
failed to act on the urine, probably because taken in too small doses, for 
it is a fair presumption that their oxidizing influence is less than that of 
potash itself. Certainly other experimenters have found that they do 
influence the urinary excretion. Golding Bird found (On Urinary De¬ 
posits , 2d Amer. ed., 1859, p. 356) that in a case carefully tested, under 
favorable circumstances, three drachms of the acetate of potassium 
increased the solids of a dog’s urine from four hundred and sixteen to 
seven hundred and eighty-two grains, or, deducting all the eliminated 
potash, to over six hundred grains. The increase of the uric acid was 
about thirty-two per cent.; of the urea, about sixty per cent.; of ex¬ 
tractives, including kreatine, kreatinine, etc., about twenty per cent.; 
or, speaking absolutely, the uric acid was increased eighty-five grains, 
the urea seventy-two grains, and the extractive thirty-six grains. Ra- 
buteau (Li Union Med., 1871, p. 389) found that the daily ingestion of 
seventy-five grains of the chloride of potassium caused an increase of 
twenty per cent, in the amount of urea discharged. Aug. Dehn has 
also experimentally found that the potash salts greatly increase the 
elimination of urea ( Pfluger's Arch., xiii. 368). 

The various studies which have been made as to the action of the 
potash salts in disease seem to bear out the oxidation theory. In six 
observations upon subjects affected with what may be termed indif¬ 
ferent diseases, such as lead-palsy, Parkes (Brit, and For. Med.-Chir. 
Bev., 1854, xiv.) found that the urea was increased, and also the sul¬ 
phuric acid, by the use of drachm doses of liquor potass®. Dr. Austin 
Flint (American Med. Monthly, Oct. 1860) has studied the effect of the 
nitrate of potassium upon a number of persons suffering from various 
diseases, and found that it very greatly increases the amount of solids 
in the urine. In rheumatism Professor Parkes found that the liquor 
potass® increased the elimination of sulphuric acid, but had no decided 
influence on the uric acid. He, however, used such small doses of the 

• 

drug as not to get the effect obtained in the alkaline treatment of the 
disease, since he expressly states that the urine remained acid (Brit. 


718 


LOCAL REMEDIES. 


and For. Med.-Chir. Rev., 1854). Rheumatism, gout, and the uric acid 
diathesis certainly bear some relation with one another. It has long 
been customary to use potash salts in excess of uric acid in the urine, 
and the relief obtained has been believed to be due to the conversion 
of the acid into a urate. Dr. Basham affirms ( Practitioner, 1870, vol. v.), 
however, that as the result of a series of analyses he has found that in 
uric acid diathesis not only is there a great increase of the urea during 
the use of potash, but also that the uric acid, either free or combined, in 
the urine is greatly diminished. Dr. Basham, remembering that Mr. 
Schunck had proved that, under the oxidizing power of potash, uric 
acid outside of the body is converted into oxaluric acid, which in its turn 
is readily metamorphosed into oxalic acid and urea, carefully examined 
the urine of gouty patients taking the potash, and found that not only 
was the urea increased, but that oxalic acid also appeared as the uric 
acid decreased, and that the urine, on standing, deposited crystals of 
oxalate of calcium, although none of these could be found in it when 
first voided. This research of Dr. Basham certainly seems to demon¬ 
strate that in uric acid diathesis the potash salt increases the oxida¬ 
tion and the ultimate metamorphosis of tissue. Where this occurs, 
whether in the blood, in the kidney, or in the urine itself, is not at 
present determined. 

Rabuteau, in his experiments with the chloride, found that the urine 
maintained its acidity. It is notorious, however, that large doses of 
the acetate, carbonate, or citrate of potassium produce alkalinity of the 
urine. The explanation of the apparent contradiction is that the vege¬ 
table salts are destroyed in the system and eliminated as alkaline car¬ 
bonates, while the nitrate, and probably chloride, sulphate, and similar 
compounds, pass entirely, or in great part, unchanged through the body. 
A proof of the latter fact is furnished by Professor Alfred S. Taylor 
( Guy's Hospital Reports , 1863, p. 177), who from the urine of a patient 
taking two hundred and seventy grains of the nitrate daily obtained 
158.7 grains of the ingested salt per diem. A portion of the potash 
salts escapes through the intestines, as Dr. Ivramer ( Annates d'Hygiene 
Publique et de Med. Leg., vol. i., 1843) has found the nitrate in the fieees 
of animals taking it; and it is much more probable that the nitrate not 
accounted for in Dr. Taylor’s investigation was eliminated by the intes¬ 
tines than that it was decomposed in the system. If, as there is much 
reason to believe, a vegetable acid when given alone passes through the 
system in great measure unchanged, while, as asserted by Dr. Munch 
(Archiv des Vereins fur gemein. Arbeiten, 1863, p. 370), and as seems to 
follow from the facts already brought forward, the same acid is found 
when combined with an alkali to be oxidized and converted into carbonic 
acid, there is in this strong corroboration of the belief that the potash 
salts increase oxidation in the system. Putting all the evidence together, 
it seems to me that the oxidation theory must be accepted as exceedingly 
plausible and probable, although not, perhaps, absolutely proved. 


DIURETICS. 


719 


When a potassium salt is given in large doses for a long time, it 
produces a condition of dyscrasia, with impoverishment and excessive 
fluidity of the blood. How or why it has this action is unknown, as 
indeed is the exact nature of the changes. Very probably there is some 
connection between these changes and the oxidizing power of the drug; 
but any theory in the present imperfect state of our knowledge could 
at best be only an ingenious speculation. 

Our knowledge of the physiological action of the potassium salts 
seems to show that the vegetable salts and the carbonates are equiva¬ 
lents, but that the mineral salts are more or less peculiar and individual; 
and clinical experience confirms this. There is, however, one excep¬ 
tion : the bitartrate of potassium appears to act differently from the 
other vegetable acid salts, and, although direct proof is wanting, prob¬ 
ably is not decomposed in the system. Potash itself is never used to 
affect the system, on account of its irritant properties; and its local 
action will be discussed under the headings of Escharotics and Antacids. 
I shall here group together all the potassium vegetable salts, except the 
bitartrate. 

POTASSII CARBONAS. 

The potash of commerce, obtained from wood-ashes and other 
sources, occurs in the form of fused, stony masses, variegated in color, 
and of a caustic, burning taste; when purified so as to form pearlash, 
it becomes of a bluish-white color. When further purified so as to con¬ 
form with the officinal tests, it occurs as a coarse, granular, whitish 
powder, very deliquescent, soluble in its weight of water, insoluble in 
alcohol. It should contain only traces of the sulphate, chloride, and 
silicate of potassium. 

Potassii Bicarbonas, U.S.— Bicarbonate of Potassium is manufac¬ 
tured by passing carbonic acid gas through a solution of the carbonate 
in distilled water. It occurs in transparent, colorless crystals, not deli¬ 
quescent, slightly alkaline to the taste and to test-paper. It dissolves 
in four times its weight of boiling water, but is insoluble in alcohol. 

Therapeutically the carbonate and bicarbonate are of equal value, 
except that the carbonate is more irritant than the bicarbonate, and is 
therefore not so well borne by the stomach. On account of its nauseous 
taste, even the latter salt is not so available as the acetate or the citrate. 
The full dose of the bicarbonate is half an ounce daily, given in diluted 
solution. 

Potassii Citras, U.S.— Citrate of Potassium is a whitish, granular, 
deliquescent salt, of neutral or very slightly acid reaction, freely soluble 
in water. It is the least offensive to the palate of all the potash salts, 
except the tartrates. The Solution of Citrate of Potassium (.Liquor 
Potassii Citratis, U.S.,—Bicarbonate of Potassium, 960 grs.; Citric 
Acid, 720 grs.; Water, 24 f*3), and the Neutral Mixture ( Mistura Potassii 


720 


LOCAL REMEDIES. 


Cit?'atis, U.S.,—Lemon-juice, Oj; Bicarbonate of Potassium, enough to 
neutralize), have been long used as diaphoretics in sthenic fevers. The 
dose is half a fluidounce to one fluidounce every one or two hours. A 
very elegant method of exhibiting neutral mixture is in the form of 
Effervescing Draught. It is especially useful when there is any tendency 
to sick stomach. It should be prepared in two solutions: one consist¬ 
ing of lemon-juice and water, equal parts, or of citric acid 5ii> water 
fgiv; the other of bicarbonate of potassium 5h water f|iii. An ounce 
of each of the solutions is to be put together, and the whole to be 
drunk during effervescence. 

Potassii Acetas, U.S. — Acetate of Potassium is a perfectly neutral 
white salt, of a decidedly saline taste, extremely deliquescent, and sol¬ 
uble in half its weight of water. It is made by dissolving the bicar¬ 
bonate in acetic acid, and evaporating. It occurs sometimes as soft, 
fibrous masses, at other times it has a foliated structure. 

Therapeutics. —An important use of the vegetable salts of potas¬ 
sium is in acute inflammatory rheumatism. Before the introduction of 
the salicylates the alkaline treatment was the best that was known for 
cases of thoroughly acute rheumatism: the medicine must be given 
freely, an ounce to an ounce and a half in the day, and be persisted in, 
opium, of course, being at the same time employed in as large doses as 
are required to relieve the pain; after a few days, when the violence of 
the symptoms has abated and decided anaemia appears, the exhibition 
of the drug should be discontinued and iodide of potassium, with tonics, 
be substituted. In cases subacute from the beginning I have found a 
combination of the iodide and acetate of potassium very efficient, ten 
grains of the former and thirty of the latter being administered three or 
four times a day. The potash probably does good in rheumatism by 
lowering arterial action, by favoring oxidation and elimination of par¬ 
tially effete materials, and by neutralizing excessive acidity. Be the 
method what it may, I have no doubt of the great clinical value of the 
remedy, its efficiency being in direct proportion to the acuteness and 
violence of the symptoms. 

As depurants, the potash salts are very useful in various diseases. 
Attention has been especially called by Dr. Golding Bird to their value in 
that class of cases spoken of as “ chronic biliousness.” In chronic malarial 
poisoning , in catarrhal jaundice , and in the jaundice of simple hepatic 
torpor , they are often of use. In uric acid gravel and in uric acid cal¬ 
culus there can be no doubt of the value of potash as a prophylactic, as 
a preventive of the formation or deposition of the uric acid. The 
remedy has also been used to dissolve uric acid calculi; but the results 
offer such slight encouragement that it is only necessary here to give a 
reference to the work of Dr. Wm. Boberts (On Urinary and Renal 
Diseases, Am. ed., 1866). 

Administration.— As usually exhibited, the potash salts are ex- 


DIURETICS. 


721 


ceedingly distasteful. There is no need of this whatever. The citrate 
may be given dissolved in lemon-juice, or, what is a still more pleasant 
method, a syrupy solution of the bicarbonate and the citrate may be 
made, of such a strength that every tablepoonful of it shall contain 
half a drachm of each salt. At the time of exhibition one or two 
tablespoonfuls of this may be put in a little water, and to it be added 
a large tablespoonful of lemon-juice, the whole to be drunk while effer¬ 
vescing. If the patient takes in the course of the day six of the 
largest doses mentioned, the whole amounts to an ounce and a half 
of the citrate of potassium. When the remedy is used simply as a 
depurant, as in jaundice, such large doses are, of course, not proper; a 
teaspoonful of the alkaline solution, with a corresponding amount of 
lemon-juice, taken three times a day, will generally be sufficient. 

Potassii Bitartras, TJ.S. — Bitartrate of Potassium , made from argol 
(see Tartaric Acid), occurs in white crystalline crusts or masses, which 
are commonly pulverized before being sold as Cream of Tartar. It 
usually contains tartrate of calcium, and is only sparingly soluble in 
cold water. It appears to differ therapeutically from its congeners in 
being more actively diuretic, and in acting more powerfully as a hydra- 
gogue cathartic. Half an ounce to an ounce of it given at once will 
very generally cause watery purging. In this city it is probably em¬ 
ployed more frequently in dropsy than any other diuretic: the usual 
plan is to dissolve an ounce of it in a pint of infusion of juniper-berries, 
and have this all taken, in divided doses, during the twenty-four hours. 
In acute desquamative nephritis , cream of tartar is a very useful diuretic: 
as, however, the avoidance of irritation of the kidneys is imperative in 
this disease, the alkaline diuretic should not be administered in infusion 
of juniper. 

The Tartrate of Potassium (Potassii Tartras, U.S.) is rarely used in 
medicine. It is said to be actively purgative in doses of half an ounce. 

Potassii Sulphas, U.S.— Sulphate of Potassium occurs in small, 
aggregated, transparent, very hard crystals, permanent in the air, 
usually short six-sided prisms, possessing a nauseous somewhat bitter 
taste. It is insoluble in alcohol, slowly soluble in nine and a half times 
its weight of cold and in less than four times its weight of boiling 
water. Sulphate of potassium is said to be “a mild purgative, operating 
usually without heat or pain or other symptoms of irritation,” in doses 
of four or five drachms; and in doses of one or two drachms acting as 
a laxative. It is, however, very rarely employed in this country as a 
purgative. Sulphate of potassium, in doses not a great deal in excess 
of those which have been recommended by practitioners, acts as an 
irritant. Dr. Mowbray states that the salt is used in Prance as a 
popular abortifacient, and that he has seen very alarming symptoms 
produced by four drachms of it. Dr. Taylor records a case in which 

46 


LOCAL REMEDIES. 


729 

less than two ounces caused in a woman severe vomiting, purging, ab¬ 
dominal pain, and finally death. At the post-mortem the stomach and 
intestines showed very decided evidences of inflammation. 

POTASSII NITRAS—NITRATE OF POTASSIUM. U.S. 

Nitrate of Potassium , or Nitre , is either obtained from certain saline 
earths, occurring chiefly in India, but to a certain extent in other por¬ 
tions of the world, or else is artificially manufactured in nitre-beds 
formed out of animal and vegetable matter, wood-ashes, and calcareous 
earth, or, finally, is obtained from old plaster rubbish. In the “ nitre- 
beds,” as well as in the natural saline earths, which have undoubtedly 
in the beginning contained animal and vegetable matters in a state of 
decomposition, nitric acid is formed by the oxidation of ammonia, and 
unites with the bases in the soil. Most of the nitre used in this country 
comes from Calcutta, through Boston, packed in grass-cloth bags. 
Chili saltpetre is the nitrate of sodium , which impregnates certain soils 
in the country whose name it bears. It is undoubtedly formed in 
these soils by a process precisely analogous to that in which the nitre 
of India is produced, except that, little or no vegetable matter being 
present to afford the potassium during the decomposition of the animal 
matter and the generation of nitric acid, the latter unites with the 
calcium of the soil. Chili saltpetre is employed as a substitute for 
true saltpetre in the manufacture of nitric acid, and may be made into 
the nitrate of potassium by means of crude potash. 

Saltpetre occurs in more or less perfect, long, striated, semi-trans¬ 
parent, six-sided prisms, with dihedral summits; of a sharp, saline, 
somewhat cooling taste; containing no water of crystallization, but 
decrepitating when thrown on the fire, from the evaporation of water 
mechanically retained in the crevices of the crystals; soluble in four 
or five times their weight of cold and in two-fifths of their weight of 
boiling water, sparingly soluble in proof spirit, insoluble in absolute 
alcohol. At a high heat they decompose, liberating a large quantity 
of nascent oxygen, and thereby greatly intensifying the combustion of 
surrounding objects. The Sal prunelle of the shops is a saltpetre which 
has been fused and run into circular moulds. 

Physiological Action. —Nitrate of potassium applied to any raw 
surface, or to a mucous membrane, acts as a violent irritant. As death 
has not infrequently resulted from its ingestion, while it has occurred 
very rarely from that of any of the other ordinary salts of the alkali, 
it has generally been thought that nitre possesses peculiar properties. 
It is not to be gainsaid, however, that the cause of the death in nitre¬ 
poisoning is very generally the local inflammation of the stomach and 
intestines produced by it,—effects dependent simply upon its irritant 
properties, and not upon any constitutional action; a conclusion be¬ 
coming doubly evident when it is remembered that if the drug be 
given in weak solution much larger amounts can be exhibited with 


DIURETICS. 


723 


only therapeutic effects than would cause death if administered in solid 
form or in very concentrated solution. Thus, in a case under the care 
of Dr. Wilks ( Guy's Hosp. Rep., vol. ii. p. 173, 3d series, 1863), a man 
suffering from renal dropsy took, between October 28 and December 
26, 1862, one pound twelve ounces and six drachms of the nitrate of 
potassium, with benefit. As one ounce has caused death in three hours 
(Taylor, Medical Jurisprudence , 2d ed., vol. i. p. 237), this patient re¬ 
ceived in fifty-nine days the equivalent of twenty-eight fatal doses. 
Again, according to Professor Stille ( Therapeutics , vol. ii.), Dr. Brock- 
lesby habitually prescribed one ounce of the salt a day, and Dr. Martin- 
Solon even two ounces per diem. 

The symptoms of poisoning by the nitrate of potassium are pretty 
constant, and yet, as in other irritant poisoning, vary within certain 
limits. Yery generally there is first an intense burning pain in the 
stomach, coming on in a few minutes after the ingestion of the poison, 
and soon followed by violent vomiting, and, it may be, free purging. 
In a little while collapse develops, with great muscular weakness, not 
rarely with local convulsive tremblings. The matters vomited, and even 
the stools, may be bloody (case, Th. Husemann, Journal fur Pharmaco- 
dynamik, 1859, ii. 178). Sometimes the nervous symptoms predominate, 
and the purging may be absent; collapse, with slight vomiting and 
with or without paralysis of the lower limbs, may alone exist. Sup¬ 
pression of urine has been noted in some cases (ease, Pharmaceut. 
Journ., Feb. 1846, p. 356). After death, very grave lesions are found 
in the stomach and the intestines, such as intense redness and conges¬ 
tion, and effusion of blood into the submucous coat, and sometimes into 
the stomach itself. Even ulceration and corrosion of the mucous mem¬ 
brane have been observed. It is evident that the symptoms previously 
detailed as existing during life are in accord with the post-mortem 
results, and all point to the irritant action of the drug as the source of 
trouble. The predominance of the nervous symptoms in some cases is 
no more than is exceptionally seen in other forms of irritant poisoning 
(see Antimony), and is no proof of a special action of the drug upon 
the nervous system. Sometimes, however, death has occurred, in poi¬ 
soning by saltpetre, with great suddenness. In the only cases of this 
character the record of which I have met with, the dose has been very 
lai’ge, and it is possible that the death was the result of the action of 
the drug upon the heart, for, like the other salts of potash, it has a 
direct paralyzing influence upon the cardiac muscle. 

Nitre has been supposed by practitioners to be especially sedative 
to the circulation; but there is no reason to believe that it is any more 
powerful as a cardiac sedative than the vegetable salts of the base. It 
certainly shares the diuretic properties of the latter, but appears to be 
more irritant to the kidneys, since it seems difficult otherwise to account 
for the suppression of urine already noted as occurring occasionally in 
poisoning by it. 


724 


LOCAL REMEDIES. 


Therapeutics. —Nitrate of potassium has been especially used in 
acute rheumatism , and when given in large doses has some favorable 
influence upon the course of the affection. It is certainly, however, a 
more dangerous remedy than the vegetable salts of the base, and, accord¬ 
ing to my experience, much less efficacious. I can therefore see no good 
reason for continuing the practice. If given, not less than an ounce 
should be dissolved in a full quart of barley-water or other demulcent, 
and be administered in divided doses during the twenty-four hours. 

In the treatment of poisoning by saltpetre, after the stomach and 
bowels have been emptied, the usual means for the relief of toxic gastro¬ 
enteritis should be resorted to. 

POTASSII CHLOPvAS. U.S.—CHLORATE OF POTASSIUM. 

This salt is said to be chiefly prepared by heating the solutions of 
the hypochlorite of lime and chloride of potassium; on cooling, the 
chlorate of potassium crystallizing out and the chloride of calcium re¬ 
maining in solution. Chlorate of potassium occurs in white rhomboidal 
plates of a pearly lustre and of an acerb taste, dissolving in sixteen 
parts of water at 60° F., and in two and a half parts of boiling water. 

Physiological Action. —Upon mucous membranes and ulcerated 
surfaces this salt acts as a powerful irritant, being, I think, even more 
active in this respect than the nitrate of potassium. Taken internally 
in sufficient quantities it is a powerful poison, and it has frequently 
caused death. There are on record a large number of fatal cases, most 
of which are collected in the brochure of Dr. J. von Mering ( Chlorsaure 
Kali, Berlin, 1885). To Dr. Jacobi, of New York, belongs the credit 
of having first called attention to the dangerous action of this much- 
used remedy (. American Med. Times , April, 1861, p. 245). The small¬ 
est amount which will produce death is not known, but in a case re¬ 
corded by Dr. Matthisson a little over half an ounce taken in the 
course of several days proved fatal. Dr. Stockvis has seen the death 
of a man after four drachms. A drachm in the course of a night has 
killed an infant a year old, and three drachms a child three to four 
years old. In most cases of fatal poisoning in the adult the dose has 
been much over half an ounce. The symptoms may be acute or sub¬ 
acute. In the rapid cases there have been violent vomiting, profuse 
diarrhoea, excessive dyspnoea, great failure of the heart’s action, and 
marked cyanosis. In most of these cases the blood has been found of 
a chocolate color. In the subacute cases the gastro-intestinal symptoms 
have been severe, with generally vomiting of blackish-green matters 
and distinct swelling of the liver and the spleen. The urine is markedly 
lessened in quantity, albuminous, often of an opaque reddish-brown or 
blackish color, showing under the microscope brownish or yellowish- 
brown tube-casts, frequently containing the detritus of blood-corpuscles. 
Hsemoglobinuria has been noticed {Trans. Internat. Congress , 1881, vol. 
1. p. 463), and methtemoglobin is a common constituent. The nervous 


DIURETICS. 725 

symptoms have been severe delirium, coma, tonic and clonic cramps, 
and a peculiar stiffness of the extremities. 

Headache, loss of appetite, violent pains in the abdomen and other 
portions of the body, and marked abdominal tenderness have usually 
preceded the loss of consciousness. Not rarely there are minute ecehy- 
moses upon the surface of the body, and even more frequently there is 
a general jaundice. In some cases the patient has rallied and seemed 
to be on the road to recovery when the fatal relapse has occurred. 

After death the blood is usually chocolate-colored, the gastrointes¬ 
tinal tract is inflamed, the liver and spleen are enlarged and filled with 
the brownish debris of red blood-corpuscles, the bone-marrow and the 
brain are often similarly colored, while the mucous membranes are 
usually swollen and ecchymosed. The kidneys are profoundly af¬ 
fected, their tubules full of brownish casts and their epithelial structure 
evincing a nephritis. The most characteristic and probably the most 
important of the lesions is the change in the blood, which was first 
noticed after death by F. Marchand ( Virchow's Archiv, Bd. lxxvii., 1879). 
Hr. L. Riess ( Berlin. Klin. Wochenschrift , 1882) noted in a case during 
life that many of the red blood-corpuscles were decolorized, and others 
contained little granules of an elliptic shape. The researches of Mar- 
chand’s most recent paper (ArcA. /. Exper. Path. u. Pharm ., xxiii.), which 
have been abundantly confirmed, show that the changes in the blood 
are the result of the formation of a substance apparently identical with 
the methaemoglobin of Hoppe-Seyler and characterized by the appear¬ 
ance in its spectrum of a blackish line in the red. The same substance 
is readily produced by mixing either the chlorate of sodium or the 
chlorate of potassium with human or animal blood outside of the body. 

It was asserted years ago by Hr. Stevens that when chlorate of 
potassium is taken internally the venous blood acquires an arterial hue, 
and the confirmatory statements of Hr. O’Shaughnessy led many of the 
profession to give credence to the idea that the chlorate yields its oxy¬ 
gen to the blood: so that it has been used to an enormous extent in 
various low forms of disease with the idea of increasing oxidation in 
the blood. It is most probable that the observers just quoted mistook 
the altered coloration of the blood for the arterial hue. It is very im¬ 
probable from a chemical stand-point that chlorate of potassium should 
part with its oxygen in the blood at the temperature of the body, and 
there is no proof that it does so. It has been shown by Rabuteau and 
other observers that chlorate of potassium escapes unchanged with the 
saliva, urine, and probably all the secretions of the body. Isambert' 
found it in the tears, the bile, the nasal mucus, and even in the milk of 
nursing women. Rabuteau took five grammes of the salt, and recovered 
from the urine 4.873 grammes. Isambert, in two experiments, recov¬ 
ered respectively ninety-five and ninety-nine per cent, of the ingested 
Chlorate of potassium from the urine. J. von Mering, out of fifteen 
grammes given to a dog, obtained 14.7 grammes; out of five grammes 


726 


LOCAL REMEDIES. 


which he took himself, he recovered 4.62 grammes; and when he 
took but a single gramme he obtained from the urine of the next 
ten hours 0.91 gramme. From the saliva and urine of a case of 
mercurial stomatitis in which five grammes had been exhibited he 
recovered 4.54 grammes. Indeed, Marchand claims, in experiments 
upon the lower animals, to have recovered all of the ingested chlorate 
from the secretions, and we must conclude that it practically all escapes 
from the body unchanged. F. von Mering believes that some of the 
chlorate of potassium is reduced in the system, chiefly because he thinks 
that methsemoglobin is formed by a process of oxygenation. The exact 
nature of methaemoglobin is, however, not made out: according to C. 
A. Macmunn ( Spectroscope in Medicine , p. 100, 1881), methannoglobin 
is probably a mixture of hsematin with soluble albumen, as it has been 
shown by Hoppe-Seyler that it is not formed by oxidation. M. von 
Mering in one or two instances in the dog found a slight increase in 
the chlorides of the urine during the administration of the chlorate, 
and it is possible that a minute quantity of the chlorate does undergo 
deoxidation, but it must be considered established that any such change 
affects so small a portion of the drug as not to be worthy of consider¬ 
ation. 

The effect of therapeutic doses of chlorate of potassium upon the 
system is certainly not marked, and is probably the same as that of the 
nitrate. The potash seems to exert some influence, as Isambert states 
that the drug directly injected into the jugular vein paralyzes the heart, 
and produces a general depression similar to that caused by the nitrate. 
In his experiments upon himself, Isambert found that when taken in 
large doses, two to five drachms a day, the chlorate caused salivation, 
free diuresis, increase of the appetite, and, when not well diluted, gastric 
irritation ; the urine continued strongly acid, and contained an excess 
of rosacic acid, uric acid, and the urates. 

Therapeutics.— The chlorate of potassium has been very freely used, 
and with great asserted advantage, in all forms of disease believed to be 
due to blood-poisoning, such as scarlet and other adynamic fevers , diph¬ 
theria, scorbutus, syphilis, and even hydrophobia. As already stated, the 
theory upon which this practice rests has no foundation in reason or 
science, and my own empirical experience with the remedy has been in 
exact accord with the teachings of physiology. I have seen the chlo¬ 
rate repeatedly employed in various diseases of the class just spoken 
of, and have never seen it do a particle of good. On the other hand, 
in mercurial and other forms of stomatitis the remedy is undoubtedly of 
great value; given in the form of a powder, with sugar, it is remarkably 
efficient in the follicular or aphthous stomatitis of children.* I do not 

* M. Laborde {Bull. ThSrap., lxxxvii., 1874) and M. Tacke ( Inaug. Diss., Bonn, 1878) 
have shown that the chlorate of sodium acts physiologically like the potassium salt; and 
Dr. S. Ringer and H. Sainsbury (London Lancet, 1882, ii. 736) have found it equally 
efficient in stomatitis. 



DIURETICS. 


727 


believe, however, that its influence in these cases is other than local; 
yet, as the remedy is eliminated with the saliva, and, therefore, when 
given internally is constantly present in the mouth, the ordinary method 
of using it is probably the best. In ascites and other dropsical affections 
it is valueless. 

When used locally , chlorate of potassium acts as a stimulant to the 
various mucous membranes, and is often of excellent service in cases of 
angina: it is even said to have been used advantageously by enemata 
in dysentery and in cholera infantum. The most generally efficient gargle 
that I know of in ordinaiy sore throat may be made by pouring a pint 
of boiling water over a powder composed of an ounce of sumach berries 
(or of their fluid extract) and half an ounce of the chlorate of potas¬ 
sium, allowing to simmer in an earthen vessel, with occasional stirring, 
to three-fourths of a pint, straining, and using in the ordinary manner. 
A half-ounce to an ounce of the saturated solution of the chlorate com¬ 
bined with a few drops of laudanum, injected into the rectum once or 
twice a day and retained, is often of the utmost service in hemorrhoids. 

Administration.— For manifest reasons, when taken in large doses 
the chlorate of potassium must be exhibited in dilute solution. The 
usual dose is from ten to twenty grains; as a lotion, from ten grains to 
half a drachm may be dissolved in the ounce of water. 

Lithii Carbonas, U.S.— Carbonate of Lithium is a white powder, 
sparingly soluble in water, and readily distinguishable by the carmine- 
red color which it imparts to the flame of alcohol. From it the U.S. 
Pharmacopoeia directs that the citrate (a white, deliquescent, freely 
soluble powder) shall be prepared by solution with citric acid in water. 
The combining number of lithia is so low that all its salts contain 
a veiy remarkable proportion of the base. We have but little accu¬ 
rate knowledge of the physiological action of lithia, but it probably 
closely resembles potash in its effects upon the system. In twenty- 
grain doses I have seen it apparently produce severe general prostra¬ 
tion, amounting almost to general paralysis, in a feeble adult female: 
but I have given it very largely to other patients without inducing any 
constitutional symptoms. It is eliminated by the kidneys, rendering 
the urine alkaline. 

Therapeutics. —According to the experiments of Dr. Ure and of 
Dr. Garrod, solutions of the lithia salts have the power of dissolving 
uric acid and the urates; and the drug was strongly recommended by 
Dr. Garrod in uric acid diathesis and in chronic gout , given in doses of 
three or four grains three times a day. The drug was extensively em¬ 
ployed, but fell into disrepute until recently, when its claims have been 
revived, especially by Professor Ditterich ( Schmidt's Jahrbucher, Bd. cli. 
p. 270). As stated by the latter observer, it is very generally given in 
■too large dose. In my own experience, given as prescribed by Dr. 
Garrod for a length of time, it has appeared to do great good in some 


728 


LOCAL REMEDIES. 


cases of chronic gout. Either salt may be exhibited dissolved in water, 
in doses of five grains, three times a day; preferably taken a half-hour 
before eating. Dr. Martineau, of Paris, affirms that he has obtained 
very remarkable results in the treatment of diabetes mellitus by the 
use of a solution of lithium carbonate and sodium arseniate in ordinary 
carbonic acid water. There is a form of diabetes closely connected with 
the gouty diathesis, and in these cases this arsenical solution of lithium 
will probably be of service: from five to ten grains of lithium carbonate 
and one-thirtieth of a grain of arseniate of sodium may be given three 
times a day. 

ALTERATIVE DIURETICS. 

BUCHU—BUCHU. U.S. 

The leaves of Barosma crenata, and of other species of the genus, 
natives of Southern Africa. These leaves, which are gathered by the 
Hottentots, are an inch or less in length, from three to five lines broad, 
of various forms, but always notched on the edges, and having a strong, 
rather rank, yet somewhat aromatic odor, and a warm, bitterish taste. 
They owe their virtues, which they yield to water and to alcohol, to a 
volatile oil and to a bitter extractive. 

Therapeutics. —Owing to its bitter principle, buchu is perhaps 
slightly tonic; but its chief medicinal virtue is as a stimulant and 
alterative to the mucous membrane of the genito-urinary organs. It 
does not very largely increase the flow of urine, and hence is never 
administered in dropsy, but in all cases of subacute or chronic inflam¬ 
mation of the genito-urinary organs it may be employed with hope of 
success. Its oil is undoubtedly absorbed, and is eliminated by the kid¬ 
neys, to whose secretion it imparts its odor. In chronic pyelitis, chronic 
cystitis, and irritation of the bladder , it is one of our best remedies, 
especially when, as is frequently the case, these diseases are associated 
with a generally-lowered systemic tone. As compared with turpen¬ 
tine, buchu is much less stimulating, and has a much more soothing etfect 
upon the mucous membranes of the genito-urinary tract. In irritated 
bladder, when the urine is highly acid, and when there is a constant 
desire to urinate, with but little relief from micturition, buchu, in com¬ 
bination with a vegetable salt of potash and the sweet spirit of nitre, 
often gives great relief. The dose of the fluid extract (Extractum Buchu 
Fluidum, U.S.) is a teaspoonful, well diluted, three or four times a day. 

Pareira, U.S. — Pareira Brava is the root of Chondodendron tomen- 
tosum, a climbing plant of South America. There appear to be in the 
root one or more alkaloids (see U.S. Dispensatory , 15th ed., p. 1085). 
Pareira Brava has been used with asserted advantage in chronic cystitis, 
in “ irritable bladder," and in chronic gonorrhoea , and appears to exert a 
stimulant action upon the mucous membrane of the whole genito¬ 
urinary apparatus. It is said to be also tonic, and slightly aperient, so 


DIURETICS. 


729 


that it is especially valuable in urinary diseases when there is feeble¬ 
ness of digestion and a tendency to eostiveness. The remedy should 
always be given in the form of the infusion (Si-Oj), or of the fluid 
extract (Extraction Tareirce Fluidum, U.S.), of which the doses are re¬ 
spectively a wineglassful and a teaspoonful three or four times a day. 

Uva Ursi, U.S.— Bearberry is the leaves of Arctostaphylos Uva- 
ursi, a low evergreen shrub, indigenous to northern maritime Europe, 
and also to our northern coasts as far south as New Jersey. They are 
from half an inch to an inch in length, wedge-shaped, thick, coriaceous, 
with a smooth, rounded margin. The odor is hay-like, the taste bitter¬ 
ish, astringent, and somewhat sweetish. Uva ursi contains gallic acid, 
besides a crystalline principle discovered by Mr. J. C. C. Hughes (Amer. 
Journ. Phar., 1847), and by him named Ursin, but now generally known 
as Arbutin. It occurs in long acicular colorless crystals, freely soluble 
in water, less so in alcohol and in ether, and is resolved by the action 
of sulphuric acid into glucose and hydrochinone. 

Therapeutics.— Uva ursi is capable of acting as a weak astringent, 
but has been long used in medicine for its influence upon the genito¬ 
urinary mucous membrane, and at present is employed only in chronic 
pyelitis, cystitis, and other affections of the genito-urinary mucous mem¬ 
brane, when a slightly stimulant and an astringent action is desired. 
Mr. Hughes found that in doses of one grain arbutin is a powerful diu¬ 
retic. It seems to be free from poisonous properties, as Jablonowski 
(Inaug. Piss., Dorpat, 1858) took in forty-eight hours eighteen grammes 
of it without discomfort. It produces a discoloration of the urine 
varying from pale greenish to dark greenish brown, the color deepen¬ 
ing upon standing. It has been proved by the researches of Von 
Mering (Pfluger's Archiv, 1877, xiv. 276), of L. Lewin (Virchow's Arcliiv, 
1883, Bd. xcii.), and of Steffen (Untersuchungen, Wurzburg, 1883) that 
the discoloration of the urine is due to the breaking up of the ar¬ 
butin in the body into glucose and hydrochinone. The change prob¬ 
ably occurs in the kidneys, as arbutin is free from toxic properties, 
while Brieger has shown that hydrochinone is poisonous, producing in 
man giddiness, ringing in the ears, lessening in the force and frequency 
of the pulse, etc. The experiments of Lewin indicate that the arbutin 
is the active principle of uva ursi, and Forster (Aerztl. Intelligenzblatt, 
1881) has shown that hydrochinone* is a powerful disinfectant and anti- 


* According to the experiments of Brieger, hydrochinone produces in man giddiness, ring¬ 
ing in the ears, and lessening in the force and frequency of the pulse. In the experiments of 
Dr. P. J. Martin ( Therap. Gaz., 1887, 289) it caused in the frog violent convulsions, followed by 
paralysis and death through failure of the respiration, both convulsions and paralysis being 
the result of a direct influence upon the spinal cord. Small doses produced in the mammal in¬ 
crease of the arterial pressure, which, if the dose were sufficient, was followed by a depression. 
When the vaso-motor system was paralyzed and the heart isolated from the central nervous 
system, the effect of hydrochinone on arterial pressure was scarcely perceptible: so that it is 
probable that it chiefly affects the vaso-motor system. The bodily temperature is lowered by 



730 


LOCAL REMEDIES. 


ferment. It is stated that a one-per-cent, solution will arrest putrefac¬ 
tion and alcoholic fermentation, while one-half per cent, is sufficient 
to check butyric fermentation. On the other hand, H. Paschkis ( Wien. 
Med. Presse, 1884, xxv. 13; confirmed by II. Laurentz, Inaug. Diss 
Dorpat, 1886) states as the result of the practical use of arbutin in 
gonorrhoea and cystitis that it does not effect much good, and that only 
a portion of it is changed into hydrochinone, most of it being elimi¬ 
nated as arbutin. He believes that uva ursi is of value in genito-urinary 
diseases, chiefly on account of its tannic acid and of the volatile oil 
which it contains, and affirms that the dried extract of the leaf, the 
best preparation, contains about three and one-half per cent, of arbutin 
to sixteen per cent, of tannic acid. In the hands, however, of Dr. Menche 
(Oentralbl. f. Klin. Med., 1883, p. 433), arbutin in doses of twelve grains 
a day has proved a very decided diuretic and very useful in cystitis. 
Whatever may be the value of arbutin, it is evident that the solid 
extract fully represents the drug, of which it is about four times the 
strength. It may be given in drachm doses three or four times a day. 
The dose of the fluid extract ([Extractum TJvoe Ursi Fluidum, U.S.) is 
two to four fluidrachms three or four times a day. 

Chimaphila, U.S. — Pipsissewa is the dried leaves of Chimaphila 
umbellata, a little indigenous perennial, distinguished from its inert 
congener C. maculata by the uniform glossy green of its leaves. The 
latter are about an inch and a half long, wedge-shaped, notched, pointed, 
and coriaceous. They contain tannic acid, bitter extractive, and, ac¬ 
cording to Mr. Samuel Fairbank, a crystalline principle, Chimaphilin 
(see U.S. Dispensatory). Pipsissewa is probably about equivalent to 
uva ursi in its therapeutic value, though perhaps not quite so actively 
diuretic. Professor George B. Wood ( Therapeutics , vol. i. p. 133) com¬ 
mends it very highly in external scrofula , asserting that he has had a 
large experience with the remedy, and that in power over the disease 
it stands next to cod-liver oil and the preparations of iodine and iron. 
He believes that it acts not only as a mild astringent and tonic but 
also as an alterative, and states that its exhibition should be long con¬ 
tinued, the administration being temporarily suspended whenever there 
is much fever. The remedy should be administered in the form of 
decoction , or of the fluid extract (Extractum Chimaphilce Fluidum , U.S.), 


large doses of hydrochinone. According to the experiments of Martin, this is mainly due to an 
increase of heat-dissipation, and is, therefore, probably the result of a vaso-motor paralysis. 
H. G. Beyer, in experiments upon the frog and terrapin {Amer. Journ. Med. Sci., April, 1886), 
comes to the conclusion that hydrochinone affects both the heart and the vessels as a paralyzant, 
lessening the rate of the heart and the amount of work done, and causing dilatation of the 
arterioles. Dr. Antaeff has found that if two per cent, of hydrochinone be added to fresh urine 
the latter will remain for many days without undergoing alkaline fermentation, but that if 
hydrochinone be added to a solution of urea a rapid decomposition of the urea occurs, which 
Antaeff believes to be the result of a direct chemical action of hydrochinone on urea ( Lancet , 
April, 1887). 



DIURETICS. 


731 


the doses of which are respectively a wineglassful and a teaspoonful 
three or four times a day. 

Juniperus.— Juniper is the fruit of the common juniper of Europe 
and this country. These berries are round, bluish bodies, about the 
size of a large pea, of a sweetish, terebinthinate, aromatic taste. They 
owe their properties to a volatile oil (Oleum Juniperi), which is officinal. 
They yield to boiling water and to alcohol. Juniper is gently stimu¬ 
lant and cordial to the stomach. Upon the kidneys it exerts a decided 
stimulant action, and the oil freely given is capable of irritating the 
renal organs above the secreting-point, and of producing lessened 
secretion, strangury, and even suppression of urine. The volatile oil 
is undoubtedly absorbed, and escapes from the system chiefly through 
the kidneys. As a diuretic, juniper has two distinct uses. The most 
usual employment of it is as an adjuvant to cream of tartar or the 
alkaline diuretics. On account of its stimulant local influence upon 
the alimentary canal, it renders the cream of tartar far more accept¬ 
able to the stomach, and at the same time aids its diuretic action. 
Sometimes juniper is employed for its stimulant action on the mucous 
membrane of the genito-urinary organs in chronic pyelitis and in chronic 
catarrh of the bladder. In the form of the compound spirit (Spiritus 
Juniperi Compositus, U.S.), or its equivalent, gin , juniper is often useful 
in the subacute congestion of the kidneys frequently seen in old persons 
and characterized by aching in the loins without other more serious 
symptoms. The inf usion is made by macerating an ounce of the berries 
in a pint of boiling water for an hour, the whole to be taken in divided 
doses during twenty-four hours. The dose of the oil is from five to 
fifteen drops; of the spirit, one tablespoonful. 

Oleum Erigerontis, U.S. — Erigeron Canadense, or Canada Fleabane, 
contains a large proportion of a yellowish volatile oil of a rather pleas¬ 
ant odor and taste, which has properties resembling those of turpentine, 
but much less stimulating. It may be employed in affections of the 
genito-urinary organs , and in passive hemorrhages. It is especially valu¬ 
able in menorrhagia. According to Dr. Starke, it is very efficacious in 
gonorrhoea (Fond. Med. Fee., 1876, p. 267). The dose is five to twenty 
drops every two or three hours, and is best administered on sugar. 

Oleum Santali, U.S., is a pale-yellowish, strongly aromatic vola¬ 
tile oil, of a pungent, spicy taste, from the distillation of the wood of 
Santalum album. It is insoluble in water, but readily soluble in 
alcohol. When pure, it is a local irritant and probably capable of 
affecting the general system, although its physiological action has not 
been properly investigated. Dr. S. Rosenberg ( Therap. Monatshefte, 
1887, p. 219) has noticed after doses of sixty drops a day irritation of 
the alimentary canal, burning in the urethra during urination, and an 


732 


LOCAL REMEDIES. 


eruption of small red prominences upon the entire surface of the body, 
involving even the conjunctiva. Oil of sandal-wood is very efficient in 
chronic bronchitis and in the advanced stages of acute bronchitis , also in 
gonorrhoea after the first period of acute inflammation. From ten to 
twenty minims of it may be given, in capsule or emulsion, three or four 
times a day. 

The stigmata op Zea Mays, or Indian corn, has been strongly 
recommended as a mild stimulant diuretic in acute and chronic in¬ 
flammations of the bladder, and in uric-acid and phosphatic gravel, and, 
I am informed, is much used by several surgeons of this city. It is 
claimed that it has a distinct aniesthetic effect in allaying the pain of 
these affections, unless there be so much mucus as to prevent contact 
with the mucous membranes. M. Landrieux, of Paris, asserts that the 
urinary secretion is much increased, and the arterial tension distinctly 
augmented, even in cases of cardiac disease {Med. and Surg. Reporter, 
1882, p. 103). Dr. Yauthier (Arch. Med. Beiges, Aug. 1880*) states that 
its activity depends upon Maizenic acid. It may be given ad libitum in 
infusion (two ounces to the pint of boiling water) ; the dose of the fluid 
extract is one to two teaspoonfuls every two or three hours; of the mai¬ 
zenic acid, one-eighth of a grain. Dr. Ducasse gives half a drachm of 
the extract a day (La France Med., 1882, p. 811). Dr. E. Stuver ( Ther. 
Gaz., vol. ii.) claims that the fluid extract (f3i every two hours, with 
acetate of potassium gr. x) exerts an extraordinary influence over acute 
gonorrhoea. 

TEREBINTHINA—TURPENTINE. U.S. 

Canada Turpentine (Terebinthina Canadensis, U.S.), or Canada 
Balsam, is the product of Abies balsamea, or Balm of Gilead, or Ameri¬ 
can Silver Fir, as it is variously named, a beautiful evergreen in¬ 
digenous to the extreme northern United States and to the British 
provinces. The juice is said to collect in little receptacles under the 
bark, and to be gathered by cutting these open and allowing them to 
drain into vessels. Canada Balsam is a thick and viscid but clear, 
yellowish liquid, containing, it is said, about twenty per cent, of vola¬ 
tile oil. The amount of the latter ingredient must vary greatly, since 
by age and exposure to the air the liquid balsam, losing its oil by 
evaporation and oxidation, becomes converted into a hard, brittle, trans¬ 
lucent, resinous mass. Canada Balsam is very rarely, if ever, used in 
medicine, but resembles turpentine in its action on the system. 

I Yhite Turpentine (Terebinthina—Turpentine. U.S.) is the con¬ 
crete oleoresin obtained by incising Pinus palustris and other species 
of pine. The supply in the Amei’ican market comes almost exclusively 
from North Carolina and other of our Southern States. It is rarely, 

* Consult also La France Mid,., 1880, xxvii. 99; L’ Union Mid., April, 1880; Med. News, 
xliii. 372. 



DIURETICS. 


733 


if ever, itself used in medicine, but by distillation is separated into a 
volatile oil and a resin (Rosin), which is officinal under the name of 
Resina. Rosin is used in medicine solely in the formation of certain 
plasters, chief among which is the Emplastrum Resince, U.S., Adhesive 
Plaster , or, in ordinary language, “ Sticking Plaster ,” which is formed 
by adding rosin to lead plaster. 

OLEUM TEREBINTHUSLE. OIL OF TURPENTINE. U.S. 

This is a yellowish, highly-inflammable oil, of a strong peculiar odor 
and a hot biting taste, moderately soluble in alcohol, freely so in ether, 
very slightly so in water. By heating with muriatic acid it is converted 
into a red liquid and a white crystalline substance, which, from its re¬ 
semblance to camphor, has received the name of artificial camphor. 
Turpentine is remarkable for having the property of absorbing oxygen 
and converting it into ozone. 

Physiological Action.— Turpentine is a powerful irritant, causing 
in a very short time inflammation in any tissue with which it comes in 
contact. 

When taken by a healthy person in moderate doses, it produces a 
sense of warmth in the stomach, soon followed by exhilaration, and, if 
the amount be sufficient, giddiness and even a species of intoxication. 
The pulse is increased in force and frequency. The turpentine escapes 
from the body through the lungs and kidneys, imparting its own odor 
to the breath, and that of violets to the urine. Although several re¬ 
corded instances prove that turpentine is capable of producing death, 
cases of serious poisoning by it are rare, and a lethal result is exceed¬ 
ingly so. The symptoms noted in poisoning by it are most of them 
constant, but vomiting and purging are present in some cases and not 
in others. Unconsciousness is generally complete, and occasionally is 
accompanied by dilated pupils; the urine is very much lessened in 
quantity, often bloody, not rarely suppressed; the skin is sometimes 
dry, sometimes moist; the pulse is feeble, rapid, and generally regular. 

The lethal dose must be very large, but it is not definitely known, 
since recovery from four ounces in an infant fourteen months old has 
been reported. In Dr. Maund’s case (Annuaire de Therapeutique, 1846), 
death was supposed to have been produced in an intemperate woman 
by six ounces; and Philip Miall has recorded an instance of death pro¬ 
duced in an infant fourteen weeks old by turpentine, of which half an 
ounce was thought to have been taken ( London Lancet , March, 1869). 

Our knowledge of the action of turpentine upon the circulation is 
very imperfect: the results which have been obtained by experimenters 
are so diverse as to indicate that different varieties of the oil affect 
the circulation differently, or else the oil alters in its physiological influ¬ 
ence when allowed to stand and absorb ozone. Dr. R. Robert, using 
the European turpentine ( Centralbl . fur Med. Wissenscli., 1877, p. 129), 
found that in moderate doses it exerted a powerful stimulating influence 


734 


LOCAL REMEDIES. 


upon the inhibitory reflex centre, and also elevated the blood-pressure 
by stimulating the vaso-motor centre. Very large doses appeared to 
paralyze both of the centres spoken of, causing decided fall in the 
arterial pressure. The respiration was first increased in frequency, but 
later strongly diminished. The blood became very dark, and the heart 
was finally paralyzed. The vagi and dejwessor nerves did not appear 
to be affected, nor indeed did any of the peripheral nerves, or the 
muscles. It is said that these results are in accord with those previously 
published by Azary in the Hungarian language, and Dr. Hoppe ( Journ . 
fur Pharmacodynamik , i. 105) concludes as the result of his own ex¬ 
periments, presumably made with European oil of turpentine, that the 
vaso-motor nerves are very early influenced by the drug. On the other 
hand, in a series of experiments made in the Laboratory of the Univer¬ 
sity of Pennsylvania by Dr. H. A. Hare {Med. News, Nov. 19, 1887) 
with American oil of turpentine, it was found impossible to raise the 
arterial pressure for more than two or three minutes, and then no more 
than ten millimetres of mercury. Large doses produced a pronounced 
fall of arterial pressure, with great cardiac depression, to which, indeed, 
Dr. Hare attributes the fall of the blood-pressure. Doses which had 
no effect on the blood-pressure increased the frequency of the pulse 
for a length of time. The increase of the pulse-rate was evidently due 
to an action upon the heart itself, for it occurred when the turpentine 
was applied directly to the heart of the frog as well as in the dog after 
section of the accelerator nerves and the vagi. When large doses were 
administered the pulse became slow,—probably, as Dr. Hare believes, 
as the result of stimulation of the pneumogastric nerves, since section 
of these nerves was followed by the normal rise in pulse-frequency. 
E. Fleischmann ( Schmidt's Jahrb., clxxx. 125) found that two drops 
produced paralysis in the frog—first of voluntary and afterwards of 
reflex activity; in the cat and in the rabbit, toxic doses abolished reflex 
activity, but caused violent lethal convulsions. The preservation of vol¬ 
untary movement after the loss of reflex activity in the frog, which 
has been confirmed by Dr. Hare, indicates that toxic doses of turpen¬ 
tine paralyze the sensory nervous system, either in the cord or in the 
peripheral nerves. 

The irritant action of turpentine upon the kidneys and genito-urinary 
tract is very decided. When moderate doses (ten drops every three 
hours) of turpentine are taken, there are usually no renal symptoms 
produced, except a slight increase of the urine. Somewhat larger 
amounts, when exhibited, are apt to give rise to aching in the loins and 
to frequent micturition, with perhaps urethral pain accompanying the 
act. If still larger quantities are ingested, these symptoms are intensi¬ 
fied, and at the same time the secretion of urine is diminished. After 
very large repeated doses of the drug, the aching in the loins is very 
great, often with spasmodic pain in the ureters; a constant desire to 
pass water struggles with the inability to micturate, caused by the 


DIURETICS. 


735 


urethral spasm; the urine is very scanty, albuminous, and even bloody; 
priapism may be present, and an intolerable irritation may affect all 
the pelvic organs. Leon Crucis ( De la Terebinthine , Paris Thesis, 1874) 
has made some experiments which indicate that when turpentine is 
given in toxic doses to rabbits it increases the coagulability of the blood 
and gives rise to numerous minute hepatic and pulmonic thrombi. 

Therapeutics. —Externally the oil of turpentine is very much em¬ 
ployed as a powerful counter-irritant. It is useful more especially when 
it is desired to act upon a large extent of surface. When a very in¬ 
tense permanent local impression is required, a blister is to be preferred. 
Thus, in pleurisy a blister may be used, in bronchitis , turpentine stupes. 
In preparing the latter the turpentine should first be warmed by setting 
the vessel containing it in hot water, then a piece of flannel, just previ¬ 
ously saturated with hot water and wrung out as dry as possible, should 
be dipped in the turpentine and again wrung out. It is then ready for 
application, and may be left on from fifteen minutes to half an hour, 
according to the sensitiveness of the skin. 

Another local use of the oil of turpentine is as an addition to ene- 
mata. From a teaspoonful to an ounce of it mixed with double its 
amount of olive oil renders opening enemata much more active, espe¬ 
cially in causing the expulsion of flatus. Turpentine enemata. contain¬ 
ing much of the oil in a small bulk are also constantly used with good 
effect in arousing the system from stupor arising from narcotic poison 
or similar causes. 

In ulceration of the bowels , turpentine taken by the stomach is often 
very efficient, probably acting locally in the intestine, and in old gas¬ 
tric ulcers good results are sometimes derived from its use. In a single 
large dose (fgss to f^i, with an equal amount of castor oil) it is an 
efficient vermifuge. It may also be used as a stimulant in loiv fevers, 
particularly when the tongue is dry and red. 

In typhoid or enteric fever it without doubt acts as a local stimulant 
to the ulcerated bowel, besides influencing the general condition of the 
system. There are two conditions or stages in the diseases named in 
which it is especially useful,—indeed, is of incalculable service. About 
the end of the second week the tongue sometimes becomes very dry, 
red, chapped, perhaps coated in the centre with a brownish fui*, and at 
the same time marked meteorism develops. Ten drops of turpentine 
every two hours dui’ing the day and every three hours during the night 
will in the majority of cases remove the bad symptoms noted. That 
the action of the oil is largely a local one is shown not only by the 
arguments of the introducer of the practice, Dr. George B. Wood, but 
also by the value of the same treatment when diarrhoea persists after 
the acute stage of the fever has passed. When convalescence is pro¬ 
tracted, when there is a constant tendency to the recurrence of diar¬ 
rhoea,—when, in other words, the ulcers of Peyer’s patches are slow to 
heal,—turpentine acts almost as a specific. 


736 


LOCAL REMEDIES. 


In typhoid bronchitis and pneumonia, especially as intercurrent in 
typhus fever and-similar diseases, turpentine applied externally and 
taken internally is often very useful. The same may be said of the 
low forms of puerperal fever. In this disease the abdomen should be 
kept covered with fomentations of the oil and of warm water alter¬ 
nately, the counter-irritant being used as constantly as a proper regard 
for the skin of the patient will allow. Internally it should be given in 
very large doses (njjx to ajjxv every two hours). 

In hemorrhages from the stomach, bowels, or lungs, turpentine has 
acquired celebrity, but it is hardly so much used as formerly. It is in 
the ataxic cases that it is useful. I have very rarely employed it, as 
the oil of erigeron has seemed even more efficacious, and is much more 
pleasant to the patient. In purpura hcemorrhagica turpentine has been 
highly praised. 

Oil of turpentine is never employed to increase the flow of urine 
for the purpose of affecting serous effusions. As a diuretic, it is used 
solely for its local influence upon the organs. Excessive diuresis some¬ 
times is apparently dependent upon a relaxed condition of the kidneys, 
and under these circumstances oil of turpentine may be of service. 
Chronic pyelitis, chronic cystitis, and gleet may be very much benefited 
by the use of the drug. 

In using turpentine in these cases, it should always be borne in 
mind that, with the exception of cantharides, it is the most actively 
stimulating of all the diuretics, and must be employed only when such 
a remedy is called for. In those comparatively rare cases of urinary 
incontinence which are dependent upon debility of the bladder, turpen¬ 
tine is sometimes of great service. When the same symptom is spas¬ 
modic, the remedy, of course, is harmful. In absolutely passive hcema- 
turia , in impotence , in certain conditions of spermatorrhoea, in amenorrhcea, 
when great local debility exists, turpentine may be tried with fair hopes 
of its being useful. The dose of turpentine is ten to fifteen drops in 
emulsion, given from four to six times a day. If glycerin and oil of 
gaultheria be added to the emulsion in such proportion that half a 
teaspoonful of the one and one or two drops of the other are taken 
with each dose, they will almost completely disguise the taste of the 
remedy. The drop of turpentine is about equal to half a minim. 

It has been asserted that oil of turpentine is a powerful bacteri¬ 
cide ; but the experiments of Koch and of Christmas-Dirckinck-Holm- 
l'eld ( Fortschritte der Med., Oct. 1, 1887) appear to show that its anti¬ 
septic properties are feeble. 

Chian Turpentine, the product of Pistacia Terebinthus, has been 
highly commended by Mr. John Clay as a remedy for internal cancer. 
Considerable testimony has been given by other physicians as to its 
value, and I have myself seen it apparently do good. Nevertheless, it 
has not fulfilled its early promise, and it is at present employed only, if 


DIURETICS. 737 

at all, with the hope of palliation. It is essential that it be genuine. 
Dose, six grains three times a day continuously. 

COPAIBA—COPAIBA. U.S. 

The oleoresin of Copaifera multijuga and of other species of Copa- 
ifera, large trees growing in Brazil. Copaiba is a yellowish liquid, of 
varying viscidity according to age, of a strong, terebinthinate, peculiar 
odor, and a bitter, burning, disagreeable taste. It mixes uniformly with 
absolute alcohol and volatile and fatty oils, and is readily dissolved by 
ether. It contains a volatile oil, a small quantity of soft, viscid resin, 
and about fifty per cent, of a hard, acid resin. In 1829, Schweitzer 
( Poggend. Annal ., Bd. xvii. pp. 487 and 1095) announced that he had 
found in copaiba a peculiar crystallizable acid, Copaivic Acid. It is not 
in the plan of the present work to discuss elaborately the chemistry of 
drugs, and consequently I must remain content with the statement that 
the researches of Professor Bernatzik (Peager Vierteljahrschrift, 1868, 
Bd. c., p. 239) have shown that very frequently this crystalline acid does 
not exist in copaiba, and hence that it is an unimportant constituent. 
Indeed, these researches seem to me to prove conclusively that copaiba 
is simply an oleoresin. 

Physiological Action.— When given in therapeutic doses, copaiba 
has very little if any action upon the general system, and the influence 
even of very large amounts is often scarcely perceptible. In the re¬ 
searches of Bernatzik (loc. cit., p. 251), eighteen grammes of the vola¬ 
tile oil were taken in three doses during twelve hours, and caused only 
an acceleration of a few beats per minute in the pulse-rate, and a rise 
of a fraction of a degree in the temperature, with, after a time, violent 
gastric and intestinal disturbance, evidently due to the local action 
of the drug, and characterized by vomiting and purging. Complete 
strangury was not produced, but there was some difficulty in passing 
the urine, which caused decided burning in the urethra. On the other 
hand, the action of the drug is much more decided upon some very 
susceptible persons, so that full doses of it produce decided fever, with 
increased frequency of pulse, and hot skin, accompanied almost always 
by decided symptoms of gastro-intestinal irritation. Sometimes, also, 
the urinary organs are more sensitive than usual to the action of the 
drug, so that strangury, and, as is stated by some authorities, even 
almost complete urinary suppression, may occur. 

In 1841, Dr. G-. O. Eey (quoted by Bernatzik) called attention to 
the fact that if nitric acid be added to the urine of persons taking 
copaiba, a precipitate is formed resembling that of albumen. This fact 
has been noted and commented on since its discovery by Dr. H. Wei- 
kart ( Archiv der Heilkunde, 1860), by Dr. Rees ( Guy's Hosp. Rep., vol. 
xvii.), by Yalentine ( Grundriss der Physiologic), and by other observers. 
In order to produce the phenomenon with distinctness and certainty, it 
is seemingly necessaiy to use large doses of the drug, since Weikart 

47 


738 


LOCAL REMEDIES. 


failed to detect it after the exhibition of small amounts of copaiba oil. 
Yarious surmises as to the nature of this precipitate have been in¬ 
dulged in; but the experiments of Bernatzik ( loc. cit., p. 252) appear 
to show that it consists of the oxidized oil united to some urinary 
principles. Dr. Bernatzik found that the elimination of the oil goes 
on slowly, continuing for as much as four days after its ingestion when 
large doses are employed. In his experiments with the resin of co¬ 
paiba, the authoi’ity just noted exhibited fifteen grammes of it inside 
of five hours. It acted as an emeto-eathartic, causing a great deal of 
pain and irritation. The urine deposited very copiously on the ad¬ 
dition of nitric acid, the resin seemingly being eliminated more abun¬ 
dantly than was the oil. Copaiba does not increase to any great extent 
the amount of the renal secretion, and no evidence has, that I am aware 
of, been offered to show that it affects materially the solids of the urine. 
Professor Quincke has recently found (Arch. f. Exper. Path. u. Pharm., 
1883, xvii. 273) a new substance, copaiba-red , in the urine of persons 
taking the oil of copaiba. The substance is a colorless acid, forming 
easily soluble salts, and has the property of reducing the oxide of cop¬ 
per and polarizing to the left. It is colored red by sulphuric acid, 
gives a characteristic spectrum, and is soluble in water, chloroform, 
and amylic alcohol, but not in ether. Its presence can be detected 
by warming the urine with concentrated sulphuric acid, when a rosy- 
red color is produced, deepening into purple-red. The color may usu¬ 
ally be developed by allowing the urine to stand with about five per 
cent, of sulphuric acid ; a precipitate forms after a time, at first color¬ 
less, but finally becoming of a dirty violet. After the use of copaiba 
resin the copaiba-red cannot be detected in the urine, but the urine 
still responds to Trommer’s test for sugar. These facts are important 
as showing how a false diagnosis of diabetes might be made. 

The clinical employment of copaiba has shown that the drug exerts 
its peculiar stimulant alterative action on other mucous membranes 
than those of the genito-urinary apparatus, and it is very possible that 
a slight elimination of the volatile oil takes place through the lungs. 

Therapeutics. —The chief use of copaiba in medicine is in subacute 
and chronic inflammations of the genito-urinary mucous membrane. In 
its action upon this structure it is a decided stimulant, but is less irri¬ 
tating and less stimulating than the oil of turpentine. Gonorrhoea is 
the disease in which it is mainly exhibited. It is especially useful in 
the advanced stages of this affection. If it be given in the beginning, 
before the inflammation has fully developed, it may sometimes succeed 
in aborting the attack, but, if it fail to accomplish this, may greatly 
aggravate the symptoms. During the height of the inflammatory 
stage, copaiba should not be employed. In other inflammatory affec¬ 
tions of the genito-urinary mucous membrane, such as pyelitis , and 
chronic cystitis , when the disease is of a subacute or chronic character, 
the remedy may be employed, it being borne in mind that in its action 


DIURETICS. 739 

it is much more stimulant than buchu or pareira brava, but much less 
so than turpentine. 

In chronic diarrhoea and dysentery, copaiba is sometimes of use, 
through its local action on the diseased surfaces. The remedy has 
been highly recommended in the advanced stages of bronchitis; and in 
the chronic form of the disorder, when attended by very free muco¬ 
purulent expectoration, I have occasionally employed it, with excellent 
results. Cojiaiba is sometimes used internally in skin-affections, but 
more frequently is employed externally as a stimulant dressing. The 
resinous mass which is left behind after the distillation of the oil of 
copaiba is stated to be an active hydragogue diuretic, increasing greatly 
the flow and lessening the specific gravity of the urine. In dropsies 
not dependent upon renal disease it is stated to be very efficacious given 
in doses of fifteen grains three times a day {Guy's Hosp. Rep., 1876). 

Administration.— The dose of copaiba is ten to twenty minims, 
repeated from three to six times a day, according to circumstances: 
the best effects are probably to be attained by the frequent use of small 
quantities. The medicine may be given dropped upon sugar, or, what 
is much better, exhibited in an aromatic emulsion, made with syrup 
and mucilage of gum-arabic in such a manner that a tablespoonful shall 
contain the required dose. When patients object to the taste, the drug 
may be given in gelatin capsules, each containing ten drops. It is 
said that these capsules do not, however, agree so well with delicate 
stomachs as the emulsion. When copaiba is rubbed up with magnesia, 
the resin unites with the earth to form a solid mass, in which the oil 
is mechanically held ( Massa Copaibce, U.S.). Pills made in this way 
are ineligible, being with difficulty disintegrated and absorbed. The 
oil {Oleum Copaibce, U.S.), which is prepared by distillation, is isomeric 
with oil of turpentine. It may be exhibited in emulsion or in capsules 
in doses of eight to fifteen minims. 


CUBEBA-CUBEB. U.S. 

The unripe berries of Piper Cubeba, a climbing plant of Java 
and other portions of the East Indies, These berries are blackish- 
veined, about the size of a small pea, and have attached to them a short 
stalk three or four lines long. Their odor is aromatic and peculiar; 
their taste warm, camphoraceous, and peculiar. Cubebs is a somewhat 
complex body, but there can be no doubt that the ethereal extract, or 
oleoresin, as it is commonly called, represents its medicinal virtues. 
The extract appears to consist chiefly of three substances,—a volatile 
oil and the brown resinous substance formed by its oxidation, a peculiar 
acid, and a neutral crystallizable principle, Cubebin. Cubebic Acid was 
first discovered by Monheim, but has been especially examined by Pro¬ 
fessor Bernatzik {Prager Vierteljahrschrift, 1864, Bd. lxxxi. p. 9). It 
is nearly tasteless, forms salts with the bases, has a very faintly acid 
reaction, and dissolves in concentrated sulphuric acid with the produc- 


740 


LOCAL REMEDIES. 


tion of (according to Bernatzik) a purple-violet color, changing on the 
addition of a little water to a cherry-red, and altogether disappearing 
when further dilution is practised. 

Physiological Action.— In some respects, cubebs, when taken in¬ 
ternally, resembles black pepper in its effects. It is, however, much 
less stimulating than its congener. After the ingestion of the ordinary 
therapeutic dose of cubebs, nothing unusual is experienced; but when 
very large amounts are taken there are evidences of gastric excitement, 
such as sensation of warmth in the stomach, and slightly-increased fre¬ 
quency of pulse and heat of skin, with perhaps some giddiness or 
headache. The urine is slightly increased in amount, and acquires a 
peculiar odor. When very large doses are ingested, the symptoms of 
gastric irritation are more severe, and the subject suffers from gastric 
burning, nausea, vomiting, and colicky pains, with, in some cases, 
purging. 

An eruption resembling urticaria has been occasionally noticed after 
the exhibition of cubebs: it is exactly similar to the eruption some¬ 
times caused by copaiba, and, like it, is probably due simply to gastric 
irritation. 

That the active principles of cubebs are eliminated by the urine is 
well established, as, after the exhibition of the drug, when nitric acid 
is added to the urine, a precipitate, resembling somewhat that of albu¬ 
men, occurs. 

The most elaborate physiological study of cubebs that I have met 
with was made by Professor Bernatzik (loc. cit.). This experimenter 
took himself, and gave to a student, ten grammes of the cubebate of 
magnesium. No decided symptoms were induced by this, further than 
some pulse-acceleration and gastric uneasiness; but the elimination of 
uric acid was greatly increased, and the cubebic acid was found in the 
urine. Half an ounce of the oil of cubebs was taken in thirty-six 
hours, the last three doses, aggregating ten grammes, being ingested in 
six hours. This was followed by very decided gastric irritation, and by 
the appearance in the urine of the oil, not as it was ingested, but oxi¬ 
dized and in the form of a resin; the eliminated uric acid was about 
one-third in amount of that excreted after the exhibition of cubebic 
acid. Of the powdered cubebs, fifty grammes Avere taken in eight 
hours; the gastro-intestinal irritation was very marked; the nitric-acid 
precipitate was abundant in the urine; the elimination of uric acid 
was about midway between the extremes of the previous exjieriments. 
According to the researches of Professor Bernatzik, cubebin is inert. 

Therapeutics.— Cubebs has been used to some extent for its local 
stimulant action upon the alimentary canal, but for this purpose is 
very inferior to black pepper and other spices. It is at present almost 
exclusively employed to influence the genito-urinary mucous membrane 
in precisely those cases in which copaiba is exhibited. The two drugs 
have very nearly the same range of action, but the cubebs is less apt 


DIURETICS. 


741 


than is the copaiba to derange digestion. Yery often the best effect in 
gonorrhoea and other genito-urinary disorders is obtained by giving the 
two remedies in combination. Cubebs is sometimes employed with 
asserted advantage in chronic hemorrhoids , and also in those varieties 
of bronchitis in which copaiba is useful. It forms the basis of certain 
proprietary lozenges much used by public speakers and others to re¬ 
lieve the relaxation of the larynx which follows slight colds or over-use. 
For this purpose the berries themselves may be chewed, and are very 
effectual. In coryza , the powdered drug used as a snuff has sometimes 
a beneficial effect. It should not be employed in the early stages before 
secretion has been established, but is indicated later in the affection, 
when the discharge is profuse. 

Administration. —The dose of powdered cubebs is from half a 
drachm to three drachms, which may be exhibited in syrup or molasses 
three times a day. The volatile oil of cubebs ( Oleum Cubebce ) is officinal, 
and may be given in emulsion three or four times a day, in the dose of 
fifteen drops, gradually increased to half a drachm, unless some effect 
is previously produced upon the urinary organs. This oil does not so 
thoroughly represent the crude drug as does the officinal oleoresin 
(Oleoresina Cubebce ), which may be given in doses of from ten to fifteen 
minims, increased as necessary. It is best administered in emulsion, 
but may be exhibited in the form of a bolus, enough sugar having been 
added to make a plastic mass. The tincture ( Tinctura Cubebce —1 to 10, 
U.S.) is an ineligible preparation ; dose, fjii to f3vi. The dose of the 
fluid extract (Extractum Cubebce Fluidum, U.S.) is ten to forty minims. 

Matico, U.S.— Mcitico , the dried tops of the Piper angustifolium of 
Peru, contains a volatile oil, resin, and, it is said, a bitter principle, 
Maticin. It is a softish mass which is largely employed as a styptic, 
and probably acts chiefly mechanically, coagulating the blood in its in¬ 
terstices, adhering to the wound, and thus arresting the hemorrhage. 
It has also been employed in internal hemorrhages , and in gonorrhoea. 
In these affections it probably acts similarly to oil of turpentine, although 
much less of a stimulant, and much more feeble. The fluid extract (Ex¬ 
tractum Matico Fluidum , U.S.) and the tincture (Tinctura Matico —1 to 
10, U.S.) may be respectively given in doses of forty-five minims and 
two fluidraehms. 

Kawa. — The root of Piper methysticum is used in the Sand¬ 
wich Islands as the basis of an intoxicating liquor known as kava- 
kava, kawa, or ava. It contains a crystalline principle analogous to 
piperin, which its discoverer, M. Gobley, called methysticin, besides 
an acrid resin, for which the name of kawin has been proposed, and a 
volatile oil. Dr. L. Lewin ( Piper Methysticum , Berlin, 1886) finds that 
when the kawa resin is injected into the frog it produces a very pro¬ 
nounced loss of sensation at the point of injection, due to a paralysis 


742 


LOCAL REMEDIES. 


of the peripheral endings of the sensory nerves, and that after the 
absorption of the remedy there is loss of voluntary motion and reflex 
activity, which is chiefly of spinal origin. In experiments made upon 
the warm-blooded animals he obtained similar phenomena,—namely, 
local amesthesia at the point of injection, followed, after absorption, by 
general paralysis, due to a direct depression of the motor side of the 
spinal cord, the motor nerves and the muscles remaining intact. Ac¬ 
cording to his experiments and those of Eandolph (Med. News, Feb. 
13, 1886), brought in contact with a mucous membrane, the resin pro¬ 
duces a burning pain, which is followed in a very short time by a com¬ 
plete and persistent loss of sensibility. Lewin ( Deutsche Zeitung, Feb. 
1886) found that six or seven minims of a solution of kawa injected 
beneath the skin produced a complete loss of sensibility in the sur¬ 
rounding area, which did not pass over for eight days. The great loss 
of muscular power which is said to follow kawa debauch in those un¬ 
accustomed to the use of the drug shows that its influence upon the 
spinal centres in man is the same as in other mammals. 

In small doses kawa is said to act as a stimulant tonic, but when 
taken in large amounts to produce an intoxication which differs from 
that caused by alcohol in being silent, drowsy, and without emotional 
exaltation. A decoction of the root is used in Oceanica very largely 
in the treatment of gonorrhoea, and recently its value has been strongly 
affirmed by Dr. Sanne ( Journ. Therap ., 1886). It is not probable that 
kawa resin will prove a local anaesthetic of practical value, because it 
is insoluble in glycerin or in water, and at first produces in sensitive 
mucous membranes great pain. The dose of the root itself, given in de¬ 
coction, is half a drachm three or four times a day; of a fluid extract, 
half a fluidounce. 

Cantharis. — Cantharides is considered elsewhere in detail (see 
Epispastics), and it is only necessary here to say a few words in re¬ 
gard to its use in diseases of the genito-urinary tract. The active 
principle of Spanish flies is certainly eliminated by the kidneys, and 
acts therefore locally upon these organs, as well as upon those over 
which their secretion flows. The influence exerted by this means is 
simply one of intense irritation, cantharides being an irritant to these 
organs in any dose sufficiently large to have an effect. Indeed, of all 
the officinal drugs cantharides is the most actively irritant to the 
kidneys and subordinate organs. Consequently it is employed only 
when an intensely stimulant action is desired, as in obstinate gleet, in 
which affection it is often combined very advantageously with the 
tincture of chloride of iron. In pyelitis and cystitis it is very rarely 
indicated, but may be cautiously employed in very chronic cases. The 
tincture of cantharides is the only preparation used internally. For 
the dose and method of administration, see Epispastics. 


FAMILY Y.—DIAPHORETICS. 


Diaphoretics are those medicines which are employed to increase 
the action of the skin. It is scarcely in place here to discuss the re¬ 
sults of suppression of the functional activity of the skin or the im¬ 
portance of the surface-elimination to the system. It does seem well, 
however, to call attention to the fact that the perspiratory glands have 
a double function to perform,—that of elimination, already alluded to, 
and that of keeping down the temperature of the body during exposure 
to heat. When a man enters a Turkish bath the temperature of which 
is perhaps 160° F., or when he works in the sun on a very hot day, 
there is, if he be used to such exposure, little or no rise in the tempera¬ 
ture of the body, because the surface-glands secrete sweat so actively 
as to expose a great amount for evaporation, and by the conversion of 
so much water into vapor such an amount of heat is absorbed— i.e., 
converted from heat into repulsive force—that the body is cooler. The 
reason that even a moderate degree of heat in a moist atmosphere is 
intolerable is because evaporation cannot take place. 

From what has already been stated, it is obvious that the use of dry 
external heat, or rather exposure to a hot atmosphere, is a powerful 
means of producing perspiration : it is, indeed, in healthy men the most 
powerful method at our command. It may be applied either in the 
form of the Turkish bath, in which the air of the hot chamber is very 
dry, or in the Russian or vapor bath, in which the atmosphere is sur¬ 
charged with hot vapor. Very wonderful therapeutic properties have 
been ascribed to the direct action of heat (Urquhart, Manual of the 
Turkish Bath, London, 1865)* when applied by the Turkish bath; but 
the remedy appears to me to act only as a powerful sudorific, perhaps 
also doing good in some cases of acute internal congestion by attracting 
the blood to the surface and thereby depleting the interior. In private 
practice, or whenever a properly-provided bath cannot be commanded, 
a very efficient and readily-applied substitute consists of a large tin 
funnel furnished with a long bent beak, a stool with a hole in the centre 


* The term Turkish Bath is here applied to the bath used in this country under that 
name. This bath appears not to be a copy of the Oriental bath, but merely a derivative from 
it. According to a writer in the British and Foreign Medico-Chirurgical Review (vol. 
xxxvii. p. 87), in the East the sudarium, or sweating-chamber, rarely has a temperature of 
more than 98° F. Consult also Bathing; How to Do It, When to Do It, and Where to Do It, 
by E. Sheppard, London, 1865; The Anglo-Turkish Bath, by Y. J. Moore, London, 1865. 

743 




744 


LOCAL REMEDIES. 


of its seat, or else a few bricks, and a large spirit-lamp. The patient 
being closely wrapped up in bed, and the clothes being especially 
“ tucked in” about the neck and shoulders, the funnel is placed upon 
the stool or the bricks in such a manner that the beak of it enters well 
under the bedclothes, coming close to but not in contact with the per¬ 
son of the sick man. The spirit-lamp, being then placed immediately 
under and close to the funnel, must, when lighted, send a column of hot 
air and vaporized water through the beak into the space around the 
body of the patient. When the lamp is sufficiently large, and a little 
care is taken to see that the nozzle of the funnel is not obstructed by 
the bedclothes, the process just detailed affords a very efficient method 
of giving a vapor-bath. 

Hot-water baths offer another very successful method of inducing 
profuse perspiration. The patient should be placed in a bath of about 
98° or 100° F., and remain there fifteen or twenty minutes, during 
which time, by the repeated addition of very hot water, the tempera¬ 
ture should be raised to 110° F., or to such point as the patient can 
endure. Warmed blankets having been plentifully provided, the sick 
man should be lifted from the bath into them, be closely wrapped up, 
and so left for three or four hours before being transferred to the usual 
bed. According to Dr. A. Steffen ( Jahrb. fur Kinderheilk., Hft. iii., 
1871), after this use of the bath the body has been proved to undergo 
loss of weight continuously for one or two days. 

Profuse sweating is always more or less exhausting, but is not 
nearly so much so as purging, and therefore may be practised in dropsical 
patients too feeble to allow of the use of purgatives. The hot baths 
are not, however, altogether free from danger or objection. Sometimes 
in the Turkish and Russian baths the patient fails to sweat freely, and 
a feeling of distress, a bounding, rapid pulse, and perhaps severe head¬ 
ache, develop themselves: under these circumstances the bodily tem¬ 
perature rises, and a fever develops, which may go on to the production 
of a true “thermic fever,” and perhaps terminate in sudden death. 
This is an exceedingly rare result, and one that never can occur if the 
patient is removed from the hot chamber so soon as any unpleasant 
symptoms are manifested. Sudden death has, I believe, taken place 
once from “ sun-stroke” in a patient while taking the “ Turkish bath,” 
also once from “ congestion of the lungs” (Brit. Med. Jour., Oct. 1878). 

The use of hot baths of any kind is, of course, contra-indicated by 
the existence of fever; but, according to Dr. Steffen, the hot-water 
baths are pre-eminently contra-indicated by the existence of congestion 
or oedema of the lungs, or of a tendency towards these disorders, since 
under such circumstances the bath greatly increases the disease, or pre¬ 
cipitates a perhaps fatal attack. My own limited experience, so far as 
it has gone, has corroborated these statements of Steffen. I have seen, 
under the conditions mentioned, the most frightful dyspnoea result 
from the use of the hot-water bath, a dyspnoea which was apparently 


DIAPHORETICS. 


745 


prevented from terminating fatally only by the removal of the patient 
from the bath-tub. If disturbance of the respiration comes on during 
the bath, the patient should be immediately taken out, and, if the symp¬ 
toms be urgent, cold water should be freely dashed over the head, neck, 
and chest. 

Diaphoretics produce the desired result in various methods, which 
may be briefly considered under four headings, representing as many 
modes of action. 

First. By relaxing the skin. As has already been sufficiently shown 
(see Cathartics, p. 666), there is a form of secretion, or perhaps it would 
be more correct to term it of leakage, from mucous membranes, which 
is distinctly paralytic in its mechanism. The same assertion may be 
made in regard to the skin: the colliquative so-called “ night-sweats” 
of phthisis afford a familiar example of this, occurring as they do in 
profoundly debilitated subjects, and at such times as there is the greatest 
relaxation of the system,— i.e., during sleep. The profuse sweats of 
collapse also may be instanced as examples of the general truth just 
enunciated. Normal processes which produce great relaxation cause 
great sweating : thus, during vomiting, especially if it be accompanied 
by much nausea, the skin pours out its secretion. By virtue of this 
general law certain remedies act as diaphoretics. All of the diapho¬ 
retics which cause sweating by producing relaxation, and which are 
employed in medicine, are nauseants, constituting a distinct group,— 
the Nauseating Diaphoretics. 

Second. By reducing the force of the circulation. There is undoubtedly 
a condition of over-action or over-rapidity of the circulation in which 
the affected glands are unable to perform readily them normal functions. 
Thus, it is well known that the first stage of inflammation is one of 
arrested secretion, and that in high fever there is a genei*al drying-up of 
the secretions. The skin does not differ from other organs in this re¬ 
spect : consequently its functional activity may fail because of excessive 
arterial action. Hence there is a class of remedies which, although 
perhaps not actively sudorific in health, are in disease very efficient in 
reducing the circulation and restoring the functional activity of the 
skin. It is evident that there is a close connection between the present 
mode of influence and that noted in the previous section; and it is no 
less apparent that the nauseant diaphoretics act most powerfully in re¬ 
ducing the circulation. There are, however, certain diaphoretics which 
act in the present method but are not nauseants: these sudorifics form 
a separate class by themselves,—the Refrigerant Diaphoretics. 

Third. By entering the circulation and directly stimulating the glands 
of the skin. It appears to be a general law that when any medicinal 
principle is eliminated by any excretory organ, the general activity of 
that organ is increased by the effort at elimination. Thus, the vomit¬ 
ing and purging of arsenical or antimonial poisoning, the increased 
urinary secretion following the ingestion of a potassium salt, are ap- 


746 


LOCAL REMEDIES. 


parently the results of attempted elimination. The skin undoubtedly 
eliminates medicinal substances, and is undoubtedly subject to the 
general law: consequently there is a class of remedies which increase 
its action by a direct influence. 

It is manifest that a drug may relax the general system, may di¬ 
minish the force of the circulation, and also may stimulate directly the 
skin : indeed, it is most probable that antimony does all of these; and 
at least some of the refrigerant diaphoretics probably act in the last 
two ways. There are, however, certain substances which seem to cause 
sweating purely by stimulating the function of the skin. These are in 
this work grouped as Simple Diaphoretics. 

Fourth. By filling up the blood-vessels. There is much reason for 
believing that precisely as under certain circumstances water, by in¬ 
creasing the amount of the blood, will provoke increased renal secre¬ 
tion, so, under other circumstances, it will cause increased dermal 
excretion. The antagonism which exists between the skin and the 
kidneys in regard to the amount of their respective secretions has 
already been sufficiently dwelt upon (see p. 726). It seems well to 
reiterate, however, that warmth favors the action of the skin, while 
cold stimulates the renal activity. Thus, large draughts of water, if 
taken cold, the patient being kept cool, increase the urine, but, if they 
be taken hot, and the patient covered up warmly in bed, increase the 
perspiration. 

Diaphoretics are employed in the practice of medicine to fulfil the 
following indications: 

First. To arrest forming diseases of not very severe type, probably 
by causing a flow of blood to the surface, and thereby relieving slight 
internal congestions, and possibly by eliminating principles which have 
been retained in the blood instead of being excreted as they ought to 
have been. In general cold, in muscular rheumatism, suppressed menstru¬ 
ation, and other results of exposure to cold and of checked perspiration, 
the diaphoretics afford the most efficient means at our command for 
restoring the normal functions. 

Second. To favor absorption. In dropsy the diaphoretics are of very 
great value, often aiding diuretics and purgatives in effecting a cure, 
and sometimes, when these fail, or when circumstances forbid their use, 
rescuing the patient from impending death. None of the medicinal 
diaphoretics except jaborandi are of sufficient power to be relied upon 
in dropsy. The Turkish, the Russian, and the hot-water bath are capa¬ 
ble of producing sufficient sweating to cause absorption of dropsical 
fluid, but must be vigorously employed. 

Third. To aid in the subsidence of diseases which naturally pass off 
with a sweat. The chief use of diaphoretics for this purpose is in 
miasmatic fevers, especially in the remittent form of the affection, when 
the sweating stage fails to develop itself thoroughly and the parox¬ 
ysms run into one another. Even in the single paroxysm of inter- 


DIAPHORETICS. 747 

mittent fever, by hastening the closing stage, diaphoretics will often 
shorten the paroxysm. 

Fourth. To eliminate noxious materials from the blood. The old 
humoral idea of the ground-work of such diseases as fevers, the belief 
in a distinct materies morbi which could be eliminated from the blood, 
has no sufficient demonstration to be accepted, and, although diapho¬ 
retics do good in fevers , yet it cannot be granted that it is in this man¬ 
ner. The very great power of increased diaphoresis in cooling the 
body through surface-evaporation has already been dwelt upon; and 
much of the good effected by diaphoretics in diseases of high tempera¬ 
ture probably has its origin in this*power. Modern science seems, how¬ 
ever, clearly to point out that this class of remedies may aid in sepa¬ 
rating from the blood retained secretions, and may to some extent 
replace the action of the kidneys when these organs are disabled by 
disease. 

In 1851, Dr. Schottin (Archiv fur Physiolog. Heilkunde , Jahrg. xi.) 
discovered urea in the sweat of patients suffering from the collapse of 
cholera. Hot only has the discovery of Schottin been confirmed by 
the researches of G. O. Kees ( Encyclopedia of Anatomy, vol. iv. p. 841), 
of Fiedler ( Diss. Inaug., Leipsic, 1854), of Hirschsprung ( Gaz. des 
Hopit ., 1865), of Kaup and Jiirgensen ( Deutsches Archiv fur Klin. Med., 
1869, Bd. vi. p. 54), of Leube (Ibid., 1869, Bd. vii. p. 3), and of G. 
Deininger (Ibid., p. 587), but it has also been abundantly proved that 
the skin excretes urea freely during the advanced stages of Bright’s 
disease, and also during the partial urinary suppression of scarlatinal 
desquamative nephritis. The urea in renal disease may even form a 
distinct crystalline powder on the skin ; but it is most abundant about 
the mouths of the sweat-glands. I believe Landerer was the first to 
announce that urea was present in the sweat of healthy persons; and, 
although chemists of excellence have been unable to detect it, its pres¬ 
ence at times can no longer be denied, since it has been found not only 
by Landerer, but also by Funke in 1858 (Moleschott’s Untersuchungen, 
Bd. vi.), by Meissner (De Sudoris Secretione, Diss. Inaug., Leipsic, 
1859), and by Leube (loc. cit .); Fourcroy (quoted by Bees) has also 
found it in the sweat of horses. By a series of elaborate experiments, 
Leube (loc. cit.) has rendered it probable, if he has not actually proved, 
that in health there is such a relation between the skin and the kidneys 
that when the former is very active the latter excrete less than the 
normal amount of urea. 

When to the facts already cited are added the observation of Grie- 
singer, that in diabetes the perspiration contains sugar, and the well- 
known circumstances that in rheumatism the sweat contains lactic 
acid, and in jaundice biliary products, the value of diaphoretics as a 
means of srettinor rid of retained excretions becomes manifest. For 

o o 

this reason, in Bright’s disease, especially of the acute form, they are 
of the greatest value, acting beneficially in thi’ee different ways,—by 


748 


LOCAL REMEDIES. 


drawing the blood to the surface, and thereby relieving any internal 
congestions of the kidneys or other organs that may exist; by pro¬ 
moting the absorption of dropsical effusions; and by eliminating retained 
secretions. 


NAUSEATING DIAPHORETICS. 

The most frequently employed medicine of this class is tartar emetic. 
This substance is so fully discussed in the earlier portion of this book 
that very little need be said about it here. It seems well to point out, 
however, that the antimonials act as diuretics, even when not given in 
doses sufficient to cause nausea, and that they do so apparently in two 
ways,—by reducing the force of the arterial circulation, and by a direct 
action. They are probably eliminated to a very slight extent by the 
skin; although this has not, to my knowledge, been proved. Tartar 
emetic is to be employed as a diaphoretic in sthenic cases only, and is 
especially used in inflammatory fevers. The dose of it as a diaphoretic 
is from the sixth to the twelfth of a grain. If a diaphoresis is urgently 
demanded, the dose should be gradually increased until decided nausea 
is induced. An excellent combination in many cases is tartar emetic, 
neutral mixture, and a minute amount of morphia. 

Ipecacuanha is another nauseating substance which, like tartar 
emetic, seems to exert an influence upon the skin, even independently 
of its action on the stomach. Moreover, like the antimonials, it never 
in small doses by itself causes profuse sweating, but simply seems to 
aid in maintaining the insensible perspiration and in keeping the skin 
soft and pliable in inflammatory fevers. Partly for this reason it is 
frequently combined with mercury in such diseases as acute peritonitis. 
The diaphoretic dose of ipecacuanha is a grain every two hours. Some 
persons with delicate stomachs are decidedly nauseated by this amount; 
and to these only half a gi’ain should be given at a time. 

A very famous and efficient diaphoretic preparation of ipecacuanha 
is Dover's Powder (Pulvis Ipecacuanha et Opii, U.S.), which contains 
one grain of opium, one grain of ipecacuanha, and eight grains of sugar 
of milk. Dover’s powder is employed in two distinct methods. In 
some diseases, as in acute rheumatism , an opiate is indicated to allay 
pain or for some other purpose, and at the same time a diaphoretic is 
needed to keep up the action of the skin. Under these circumstances, 
from three to five grains of the compound powder of ipecacuanha may 
be given every two, three, or four hours, pro re nata. The medicine is 
more apt to nauseate when taken in powder than when exhibited in 
pills; for which reason the latter form of administration is preferable 
in the class of cases now under consideration, especially as the powder 
is to most persons a disagreeable medicine. In the second method of 
using Dover’s powder, a single large dose is given for the purpose of 
producing profuse sweating. In the intense suffering which sometimes 
results from suddenly suppressed menstruation , the remedy is most effi- 


DIAPHORETICS. 


749 


cient, alleviating the pain and aiding in the production of the desired 
diaphoresis. In breaking up a cold , or in muscular rheumatism , Dover’s 
powder is often used to cause sweating (see Alcohol as a Diaphoretic). 

REFRIGERANT DIAPHORETICS. 

Aconite, veratrum viride, and all the various remedies used to depress 
the cardiac action when excited, are, in the strictest sense of the term, 
refrigerant diaphoretics. Sufficient has, however, already been said in 
regard to their use. The citrate of potassium , whether in the form of 
effervescing draught or of neutral mixture, is constantly employed in 
sthenic fevers, and affords, I think, the best basis there is for fever- 
mixtures in such cases, the more powerful depressants being added to 
it as circumstances demand. 

SIMPLE DIAPHORETICS. 

PILOCARPUS. U.S.—JABORANDI. 

This drug, which has long been employed by the natives of South 
America, received its first notice, under the various names of Jaborandi, 
Jaguarandy, and Jamguarandi, from Dr. T. J. H. Langgard in his 
“Diccionario de Medecina domestica,” Rio Janeiro, 1865. It attracted 
no attention, however, until 1874, when it was brought to Paris by 
M. Coutinho. Its botanical source is Pilocarpus pinnatus, a member 
of the rue family. The leaves are oval, elongated, entire, 1.2 to 1.5 
inches long, and one-third to one-fourth as broad; their taste is bitter, 
and their odor hay-like: they contain an alkaloid, pilocarpine, dis¬ 
covered by Byarson.* The nitrate of pilocarpine is readily obtained 
in white lamellated crystals, and is soluble in eight parts of distilled 
water. The virtues appear to reside exclusively in the leaves and bark, 
Dr. Frerichs ( Berlin . Klin. Wochenschrift, 1875) having found the wood 
inert.f 

Physiological Action.— When an infusion of from sixty to ninety 


* A second alkaloid has been discovered by E. Harnack and H. Meyer and named jaborine 
{Arch. f. Exper. Path. u. Pharm., xii.). It is a derivative of pilocarpine, and is said frequently 
to contaminate the commercial alkaloid. Its discoverers assert that they have studied its 
action upon the heart, pupil, intestines, and salivary glands, and found it identical with that 
of atropine. Its presence has no doubt been the cause of some contradictory results obtained 
by experimenters with pilocarpine. According to Professor Harnack, pilocarpine is readily 
converted into a second alkaloid, pilocarpidine, which produces, when in sufficient doses, ex¬ 
cessive sweating, salivation, and also violent vomiting and purging, with colicky pain. In 
toxic amounts it causes great disturbance of the circulation and wide-spread muscular weak¬ 
ness. On the frog’s heart, in small amounts it acts as an excitant, but in larger doses as a 
paralyzant. It is a very feeble local myotic. In its general influence it is very much less 
powerful than is pilocarpine ( Archiv f. Exper. Path., vol. xx.). Another derivative alkaloid 
is jaborandine, which Harnack has found to act on the frog’s heart somewhat like atropine. 

| Under the name of Jaborandi various drugs other than the product of Pilocarpus pin¬ 
natus are sold in Brazil. As the Pilocarpus pinnatus has been found to be active when grown 
in France, it is probable that it might be successfully cultivated in our Southern States. 



750 


LOCAL REMEDIES. 


grains of jaborandi is given to an adult, in about ten minutes the face 
and neck become deeply flushed, and free perspiration and salivation 
commence. After a hypodermic injection of the alkaloid, the symp¬ 
toms may set in in six minutes. The sweating begins on the face; 
both it and the salivation are excessively profuse, and last from three 
to five hours. There is not rarely nausea, and sometimes even vomiting. 
The pulse is usually more or less quickened, as is also frequently the 
respiration. After the sweating has ceased, the patient is left more or 
less exhausted. The nasal and lachrymal secretions are also very gen¬ 
erally increased under the action of the drug, and M. Gubler has noted 
diarrhoea, which in the experiments of Ringer and others has not been 
present. There is sometimes contraction of the pupils, and even dis¬ 
turbance of vision. These effects of the drug are in the adult fairly 
constant; but subjects have been occasionally found who were not 
susceptible to the action of the remedy, and, very curiously, in Dr. 
Ringer’s experiments children were found to be very unsusceptible, 
although doses of sixty grains were employed. Schwann, M. Morat 
(.Lyon Med., Juillet, 1882), and other observers have noticed in the 
lower animals that very violent gastric and intestinal movements are 
produced by the drug. 

Secretion. —The sweat produced by jaborandi is often enormous in 
quantity (nine to fifteen ounces by estimation). It is stated to be at 
first acid, then neutral, and finally clearly alkaline. Vulpian ( Legons s. 
Subst. toxiq., Paris, 1881, 87) denies that even the first sweat has other 
than alkaline reaction, and believes, with MM. Luchsinger and Trumpy } 
that there has been a mistaken observation, due to the fact that the 
secretion of the sebiferous glands is acid. In the analyses of M. Robin 
the chlorides were found in excess, the carbonates and phosphates in 
verv minute amount, and the urea in more than five times its normal 
proportion, the amount eliminated in the sweating being estimated at 
from ten to fifteen grains. MM. Hardy and Ball believed that in their 
experiments the average amount of urea eliminated by the skin was 
seventeen grains (Journ. de Therap., 1874). Pilicier noted in a dog 
with a gastric fistula great increase of the gastric juices ( Med. Cen- 
tralbl., 1876, 430); the biliary secretion appeared to be lessened. On 
the other hand, M. Morat ( Lyon Med., July, 1882) has noted a tem¬ 
porary increase of the sugar in the blood, an evidence that the glyco¬ 
genic function of the liver is stimulated. Dr. Hammerbacher has 
found the secretion of milk lessened {Arch. f. Gesam. Physiolog., xxx. 
236). Whether or not the urine is increased in healthy persons when 
pilocarpine is given in a single large dose may be considered uncertain, 
but the assertion of M. Gubler that the alkaloid administered in very 
small repeated doses has a marked diuretic influence has received clin¬ 
ical confirmation. Much interest attaches to the effect of jaborandi 
upon urea-elimination, but it cannot be considered as determined, ex¬ 
cept that in various diseases the combined renal and dermal elimina- 


DIAPHORETICS. 


751 


tion is greatly increased by the drug. Hardy and Ball state that in 
health urea-elimination from the kidneys is diminished by the drug, 
while Professor Tyson and Dr. Bruen have found it increased both in 
health and in disease. The experiments have, however, been too few, 
and especially the conditions of their performance too lax, for much 
importance to be attached to them. 

There appears to be some relation between the flow of saliva and 
that of perspiration produced by jaborandi: if the one is very profuse 
the other is often, but not always, correspondingly scanty. Sometimes 
the salivation almost replaces the sweating (Fereol, Journ. de Therap., 
Jan. 1875); very frequently it commences before the sweating, and 
often it is more persistent. During it the mouth is warm, and there is 
often a feeling of tenseness about the maxillary glands. The saliva 
contains an abundance of salts and of ptyaline, as well as a small 
excess of urea ( Boston Med. and Surg. Journ., p. 347). Pilicier, it is 
true, states that the proportion of albuminous compounds, and es¬ 
pecially of sulphocyanide of potassium, is much diminished, but in M. 
Robin's analyses the proportion was even beyond the normal, and Ch. 
Bougarel has by careful experimentation shown that the power of jabo- 
randi-saliva in converting starch into sugar is equal to that of the 
normal secretion. According to I. N. Langley (Brit. Med. Journ., p. 
247), in the frog the mouth and skin, after the exhibition of jaborandi, 
become covered with a viscid secretion; in the dog, the rabbit, and the 
cat there is profuse salivation. The effect upon the salivary secretion 
must be due to a direct influence upon the gland, as it is produced 
equally well after section of all of the salivary nerves (Langley, 
Journ. of Physiology, 1878, 339; Carville, Journ. de Therap., 1875; con¬ 
firmed by Schwann, Med. Centralbl., 1875, p. 440) ; also when the drug 
is injected directly into the gland and prevented from entering the 
general circulation (Langley). According to the elaborate experi¬ 
ments of Langley, very small doses cause in the cat great increase of 
the secretion. Stimulation either of the chorda or of the sympathetic 
nerve causes respectively some increase or lessening of the secretion, 
but this increase or lessening is not nearly equal to that which occurs 
in the normal animal, and is due to the action of the nerves upon the 
circulation, and not to any influence of their secretory fibres. Yery 
large doses of the drug injected into the gland immediately arrest the 
secretion, and doses of less size given in the same way, while increasing 
secretion, paralyze both chorda tympani and sympathetic nerve, so 
that stimulation of them has no effect. It is probable from the last 
fact that jaborandi has an action upon the secretory gland-cells. 

Although the evidence just deduced indicates that an influence is 
exerted by jaborandi upon the gland-cells, the fact that atropine arrests 
the jaborandi salivary secretion prevents us from considering it settled 
that the drug does so act upon the salivary gland cells rather than upon 
the peripheral nerve-endings, since there is reason for believing that 


752 


LOCAL REMEDIES. 


the sweating which the drug causes is due to au action on the nerve- 
endings. Dr. Fuchsinger (confirmed by Hawrocki) has found that 
section of the nerves of the cat’s leg did not prevent the paws from 
sweating when jaborandi was exhibited. This demonstrates that the 
action of the drug is peripheral, not centric. Five or six days after the 
section, when the peripheral nerve-endings had undergone degeneration, 
Fuchsinger found that jaborandi was unable to excite sweating. This, 
however, can hardly be considered to prove absolutely, as Fuchsinger 
claims, that the drug acts upon the peripheral nerve-endings and not 
directly upon the glandular cells themselves, since it is probable that 
these glandular cells shared the anatomical changes of the nerve-endings 
(. Pjiuger's Archiv , xv. 482). 

Jaborandi appears to stimulate the nutrition of the hair, and Pro¬ 
fessor Prentiss, of Washington, has reported several cases in which the 
continued internal use of pilocarpine caused the hair to become exceed¬ 
ingly coarse and to change* its color from light to dark ( Phila. Med. 
Times, xi. 610). Dr. H. Rasori has noticed a tuberculated eruption ap¬ 
parently produced by jaborandi {Trans. Internal. Med. Cong., 1881, iii. 
146). M. Groeco has found that pilocarpine hypodermically injected or 
locally applied sensibly affects hysterical ansesthesia ( Land. Med. Record, 
1882, 137). 

Temperature. —The action on the bodily heat varies somewhat. M. 
Robin affirms that before and during the early stages of the sweating 
from jaborandi the temperature rises 1° to 2° F., but afterwards falls 
as much below the normal point and remains depressed for one or two 
days. This primary rise of temperature has been noted by other ob¬ 
servers (Ringer, Lancet, 1873, i. 157; Greene, Phila. Med. Times, vi. 
56; Scotti, Berlin. Klin. Wochens., 1877, 141; Pilicier,* Med. Centralbl., 
1876, 429; Weber, Ibid., 770), but is certainly frequently absent alto¬ 
gether or very trifling.f The subsequent fall of temperature seems to 
be a very constant phenomenon when the action of the drug is suffi¬ 
ciently severe; it probably depends in great part, or altogether, upon 
the loss of heat during the sweating. 

Circulation .—The action of jaborandi upon the circulation has been 
studied by Mr. Langley ( Journ. of Anatomy, x. 188), E. Leyden ( Berlin. 
Klin. Wochenschr., 1877, 406), Kahler and Sayka {Med. Centralbl., 1876, 
541), and Harnack and Meyer {loc. cit., p. 374). The phenomena noted 
by these observers are in most respects in accord, but Kahler and Sayka 
using the extract of jaborandi, and E. Leyden commercial pilocarpine, 
have found the pulse either as a constant or occasional phenomenon at 
first increased in its rate, while Harnack has never seen this with chemi- 


* Pilicier noted that the rise occurred in the axilla, but not in the rectum: this would 
indicate that it is a local phenomenon, the result of a heating of the surface, not of the in¬ 
terior, of the body. 

f Consult Riegel, Berlin. Klin. Wochenschr., 1875, 86; Bardenhewer, Ibid., 1877, 8; 
Auschmann, Ibid., 353. 



DIAPHORETICS. 


753 


cally pare pilocarpine. Immediately after the injection of the alkaloid 
into the jugular vein the arterial pressure falls, but in a few moments 
the characteristic phenomena of a slow pulse with increased arterial 
pressure come on. This slowing of the pulse is not prevented by pre¬ 
vious section of the pneumogastric, but is at once set aside by an injec¬ 
tion of atropine (Langley, Leyden, Harnack, and Meyer) ; as is also the 
diastolic arrest of heart which pilocarpine produces in the frog. Har¬ 
nack and Meyer therefore believe that in both the frog and the mammal 
the chief cardiac influence of the alkaloid is exerted upon the intra- 
cardiac inhibitory ganglia; but Professor Ringer ( Practitioner , xxvi. 
12) finds that jaborandi and atropine act antagonistically upon the 
ventricles separated from the auricles, and, as the ventricles contain no 
inhibitory ganglia, some other explanation of the antagonism must be 
found.* The rise of the arterial pressure is stated by Harnack and 
Meyer to be prevented by the use of curare and artificial respiration, 
and to be, therefore, a secondary, not direct, result of the drug’s action: 
it is probably due to the convulsive muscular contractions produced by 
the drug. In the latter stage of the poisoning the arterial pressure 
falls. As in the experiments of Harnack and Meyer asphyxia in this 
stage did not cause rise of pressure, although the heart appeared still 
to retain its force, the vaso-motor system is probably paralyzed. The 
pulse still continues slow, although, according to Harnack, the vagi are 
completely paralyzed. 

Sexual Organs. —Jaborandi does not appear to have any power over 
the sexual organs, except the pregnant womb. Cases of abortion 
during its use have been reported by M. Masmann (quoted by Larvand, 
La Pilocarpine , 1883) and by Schanta ( Wiener Med. Wochens., Ho. 18, 
1878), but in the hands of other observers the drug has appeared to 
have little, if any, abortifacient influence, and M. Hyernaux and M. 
Chanteril have found it powerless in the lower animals (quoted by 
Larvand). When, however, the pregnant female is at her full term, 
the drug may affect the uterine contractions, as Larvand and others 
have noted an increase of the pains, or even a precipitation of labor, 
both in women and in the lower animals. Nevertheless, the oxvtocic 
powers of jaborandi are very feeble. (See British Medical Journal , 
1879, ii. 509; also Wien. Med. Blatt, 1879, ii. 1178, 1207.) 

Motor System. —In man, muscular tremblings have been observed 
during the action of jaborandi, but it is doubtful whether thej^ are due 
to a direct action of the remedy. In the frog, as first noticed by Mur¬ 
rell ( Pharm. Journ. and Trans., vi. 228), small doses (3 mgrm. of pilo¬ 
carpine) produce violent convulsions with heightened reflex activity, 
while larger amounts cause complete palsy. According to Harnack 

* Professor Ringer’s explanation seems at present the most probable. It is, that pilocar¬ 
pine paralyzes the heart by combining with the molecules of the excito-motor apparatus and 
of the muscular tissue, and that atropine displaces the pilocarpine and thereby substitutes its 
own action. 


48 



754 


LOCAL REMEDIES. 


and Meyer, the convulsions are due to spinal stimulation, and the 
paralysis partly to overwhelming of the spinal centres, and partly to 
paralysis of the muscles, the motor nerves themselves not being af¬ 
fected. The action of the drug upon the musculo-nervous system is 
entirely subservient to its other effects. 

Eye. —When applied to the eye, pilocarpine produces great contrac¬ 
tion of the pupil, tension of the accommodative apparatus, and an 
approximation of the nearest and farthest points of distinct vision 
(John Tweedy, Lancet , 1875, i. 159; C. Scotti, Berl. Klin. Wochens ., 1877, 
143; Galezowski {Med. Times and Gaz., 1877, ii. 358). Mr. Tweedy 
also states that there is impairment of vision, due to benumbing of the 
retina. According to P. Albertoni, the myosis is followed by a moderate 
but persistent mydriasis, and is not prevented by previous section of 
the oculo-motor nerve or of the upper cervical sympathetic ganglion. 
It is certainly the result of a peripheral influence. Galezowski, who 
uses a solution of one part of a pilocarpine salt in fifty parts of water, 
affirms that it answers as well as a solution of eserine in diseases of the 
eye, and has the great advantage of not producing irritation. 

Therapeutics. —Jaborandi is so powerful and certain in its diapho¬ 
retic action that it has already taken rank as the most reliable and in¬ 
fluential of the remedies of its class; indeed, so great is its power that 
it has widely extended the use of diaphoretics. It is doubtful how 
far it is applicable to the treatment of fevers, although the decided 
lowering of the temperature by it would indicate a power over such 
bodily conditions. In bilious and other malarial fevers it is probably of 
value, but sufficient use has not as yet been made of it to determine its 
exact powers in hastening the desired remission. In typhoid and other 
asthenic fevers it would probably do much injury. In dropsies it has 
been widely employed, and certainly is a most efficient remedy. It 
appears to be as safe in asthenic dropsies as in any other remedy com¬ 
parable with it in power, although in my own observation a free jabo¬ 
randi sweat is almost as exhausting as a purging. Great value has been 
ascribed to it in facilitating the removal of local watery effusions, such 
as occur in pleurisy , etc. Cases of pidmonic oedema have been reported 
in which lives seem to have been saved by its employment. In uraemia 
it is the most efficient remedy at our command. In acute or chronic 
Bright's disease it is of great value, sufficing often in the one case to 
bring about convalescence, and in the other greatly to prolong life and 
make it comfortable. The sweats may be repeated daily, bi-weekly, 
or weekly, according to the circumstances of the case. In subacute 
and muscular rheumatism jaborandi is very efficient. 

The action of the remedy on the kidney is still sub judice. Purjesz 
{Deutsch. Arch. f. Klin. Med., xvii. 533) has noted one case in which 
the drug seemed to produce albuminuria, but the occurrence may have 
been accidental, and there is clinical experience to show that when the 
pilocarpine is given in doses of one-tenth of a grain three times a day, 


DIAPHORETICS. 


755 


so as to avoid any violent action upon the skin, there is a decided in¬ 
crease of the urine. In a case of my own, the urine, which had been 
absolutely suppressed for seventy-two hours, reappeared immediately 
after the hypodermic injection of one-twelfth of a grain of pilocarpine 
nitrate. The case of Purjesz and the occasional occurrence of strangury 
after the drug (my own experience, also Stumpf’s, Deutsch. Arch., xvi.) 
would indicate that it stimulates the urinary organs, and that some 
caution must be exercised in its employment in the earliest stages of 
acute tubular nephritis. Professor Ringer has reported several cases of 
unilateral sweating cured by the use of full doses of pilocarpine given 
hypodermically ( London Tract., xvii. 401), and it has been used with 
asserted success in alopecia. It has been extensively used in diphtheria 
and croup, but has no direct influence over the disease, and may do great 
harm in adynamic conditions: b} T increasing the glandular secretion of 
the bronchial tubes it may aid in loosening the membranes. 

M. Cheron has used the nitrate of pilocarpine hypodermically with 
very good success when the milk is becoming scanty in nursing women. 
The dose must not be large enough to produce diaphoresis,—not more 
than one-twelfth of a grain. 

Locally applied (half-ounce of the leaves) in the form of a poultice, 
jaborandi may sometimes produce local sweating only, but I have seen 
very marked and extraordinarily prolonged general sweating so caused. 

Administration. —The dose of jaborandi is forty grains to a fluid- 
drachm. The fluid extract (Extractum Pilocarpi Fluidum , TJ.S.) may 
be used in doses of half a drachm to a drachm. Pilocarpine is superior 
to jaborandi in the certainty of its action, and in being less disagree¬ 
able, and probably less apt to nauseate. Weber, Bardenhewer, and 
Auschmann agree that 0.3 of a grain of it is equal to seventy-five 
grains of the best leaves; but this is probably an overestimate of its 
powers. In the form of the hydrochlorate (Pilocarpince Hydrochloras, 
U.S.) it may be used hypodermically in watery solution, the dose being 
from one-eighth to one-third of a grain. Dr. Demme, of Berne, gives 
to children between one and two years old 0.075 grain; between two 
and six, 0.1 to 0.15 grain; between six and twelve, 0.15 to 0.35 grain, 
and finds it to work very well ( Med. Times and Gaz., 1877, ii. 636). 
No fatal results have as yet been reported, although Auschmann has 
twice seen alarming collapse follow moderate doses, apparently pro¬ 
duced by excessive vomiting ( Berl. Kim. Wochenschr., 1877, p. 356).* 

Antagonism with Atropine. —In February, 1875 (Brit. Med. Journ .), 
Mr. Langley called attention to the antagonism existing between jabo¬ 
randi and belladonna. When the heart has been slowed or arrested 
by jaborandi, atropine will bring the rate of pulsation almost to normal; 
the reverse of this also occurs, provided the amount of atropine pre- 


* A case of poisoning to which I have not had access is reported in Bull, et MSm. Soc. de 
Thirap., s6r. 2, v. 88. 



756 


LOCAL REMEDIES. 


viously applied has not been too great (Langley, Journ. Anat., x. 194). 
Upon the sweat-glands the two drugs have also antagonistic powers, 
one being able to annul the action of the other (Luchsinger, loc. cit.'). 
The same is true in regard to the salivary secretion (Langley). This 
antagonism between atropine and jaborandi is affirmed by H. Larvand 
to extend to the intestines and pupil. In belladonna-poisoning the alka¬ 
loid has been used with no advantage in very small dose (. Lancet , 
1876, i. 346), but in a case in which nine-tenths of a grain of atropine 
had been taken, nine grains of pilocarpine are said to have been in¬ 
jected hypodermically in between one and two hours with success 
(Professor Purjesz, Pest. Med.-Chir. Presse , 1880). Dr. L. Juhasz re¬ 
ports (Klin. Monatsbl. f. Augenheilk ., xx. 86) a case in which it was 
estimated that about one and a half grains of atropine were taken, 
followed in half an hour by vomiting; four and a half grains of pilo¬ 
carpine were injected in about seven hours, with a favorable result. 
Dr. Hofferts reports ( Wien. Med. Presse, 1883, xxiv. 1412) a case in 
which seven and a half grains of extract of belladonna were ingested, 
and nearly two grains of pilocarpine given, with recovery. 

LIQUOR AMMONII ACETATIS—SOLUTION OF ACETATE 

OF AMMONIUM. U.S. 

Spirit of Mindererus is prepared by saturating dilute acetic acid 
with carbonate of ammonium, and consequently consists of a solution 
of acetate of ammonium containing as much of free carbonic acid as 
the water will absorb. It is a colorless liquid, and should have no 
odor, or a very faint odor of acetic acid. Any specimen having an 
ammoniacal odor should be rejected, as containing an objectionable ex¬ 
cess of carbonate of ammonium. The taste is disagreeable and saline. 
As the solution upon standing undergoes decomposition after a time, 
it should be freshly prepared when needed. 

Therapeutics.— Spirit of Mindererus appears to be a feeble stimu¬ 
lant diaphoretic. Cullen has known eight ounces of it to be taken in 
a very short time without inducing any effect; yet the testimony is 
very strong as to its having some value in disease, and in adynamic 
fevers it may be employed as a diaphoretic. It is, however, much less 
efficient than the sweet spirit of nitre, and is probably to most persons 
more disagreeable than that favorite drug. Special value has been 
claimed for it in dysmenorrhcea , and even in menorrhagia ; but I do not 
believe that it has any superiority over other diaphoretics in the former 
affection, and its being of any use in the latter disease seems apocry¬ 
phal. The dose is one to two tablespoonfuls. 

SPIRITUS AETHERIS NITROSI—SPIRIT OF NITROUS 

ETHER. U.S. 

Sweet spirit of nitre is prepared by adding sulphuric acid to alcohol, 
then adding copper wire, and after this nitric acid, distilling at a tern- 


DIAPHORETICS. 


757 


perature not exceeding 180° F., and adding alcohol to the distillate. 
The first reaction which takes place between the sulphuric acid and 
the alcohol results in the liberation of ether, the hydrated oxide of 
ethyl; the nitric acid, giving to the copper two of its equivalents of 
oxygen, is converted into nitrous acid, which combines with the oxide 
of ethyl to form a nitrite. Spirit of nitrous ether is a volatile, inflam¬ 
mable liquid, of a pale-yellow color inclining slightly to green, having 
a fragrant, ethereal odor, free from pungency, and a sharp, burning 
taste. It slightly reddens litmus, but does not cause effervescence when 
a crystal of bicarbonate of potassium is dropped into it. When mixed 
with half its volume of officinal solution of potassa previously diluted 
with an equal measure of distilled water, it assumes a yellow color, 
which slightly deepens, without becoming brown, in twelve hours. A 
portion of the spirit in a test-tube half filled with it, plunged into water 
heated to 145° and held there until it has acquired that temperature, 
will boil distinctly on the addition of a few small pieces of glass. Spirit 
of nitrous ether has the specific gravity 0.837, and contains five per 
cent of its peculiar ether. It should not be long kept, as it becomes 
strongly acid by age. 

Physiological Action.— Undoubtedly the sweet spirit of nitre, if 
taken in sufficient amount, acts very decidedly upon the organism. Mr. 
D. R. Brown reports [Pharm. Journ. Trans., March, 1857) the effects 
of the inhalation of sweet spirit of nitre. The first symptoms are a 
bluish-purple, livid discoloration of the lips and fingers, and a peculiar 
pallor of the face. These increase, the face assumes a ghastly look, the 
extremities grow cold, and the pulse becomes very weak and frequent, 
but the breathing remains slow and regular; muscular weakness is ex¬ 
treme, and the least exertion causes hurried respiration, with painful 
oppression in the chest, and cardiac distress. Confusion of mind and 
giddiness may or may not occur, but headache always comes on sooner 
or later. These symptoms are very similar to those caused by toxic 
doses of other nitrites, and it is most probable that the drug simply 
unites the physiological effects of the nitrites in general with those of 
alcohol. In sufficient amount sweet spirit of nitre is undoubtedly an 
active poison. Dr. Christison reports the case of a woman whose death 
was attributed to it, and between three and four ounces killed a child 
three years old in twelve hours, the symptoms closely resembling those 
of alcoholic poisoning with the addition of vomiting and purging 
[Lancet, 1878, ii.). In therapeutic doses it has do marked action, except 
in increasing the secretion of the skin and kidneys, and in a slight 
degree stimulating the nervous system. In children it is often of value 
as an antispasmodic. 

Therapeutics. —Sweet spirit of nitre is one of the most popular of 
the diaphoretics. As it exerts a stimulant action, it is useful in ady¬ 
namic rather than in sthenic fevers. In children with fever offering ner¬ 
vous symptoms, such as starting, jerkings, etc., it is especially useful. 


758 


LOCAL REMEDIES. 


If the patient be kept about and cool, instead of being warmly covered 
in bed, spirit of nitrous ether acts as a decided diuretic; but it is not 
sufficiently powerful to make it worthy of reliance in dropsy. The dose 
of sweet spirit of nitre is: for an adult, a teaspoonful to a tablespoon¬ 
ful; for a child three years old, half a teaspoonful. If a diaphoretic 
action is required, very minute doses should be exhibited at short in¬ 
tervals. Thus, for a child a year old, a teaspoonful should be put in 
five ounces of water, and a tablespoonful given every hour. 

Alcohol.— As is known to every hard drinker, alcohol when taken 
in excess, and especially if drunk with hot water, is eliminated by the 
skin, and often causes profuse sweating. As a diaphoretic it is, how¬ 
ever, used in medicine for only one purpose,— i.e., in those cases, such 
as a forming “ cold,'” subacute rheumatism , and suppressed menstruation, 
when a single profuse sweating is desired. In these cases I have found 
the following plan most efficacious, provided the patient have not de¬ 
cided fever: a Dover’s powder is administered, and directly after this 
the patient goes into a hot-water or vapor bath, or else does what is 
known in common parlance as “ soaking his feet,”— i.e., takes a pedilu- 
vium. The proper method of doing the former of these acts has been 
sufficiently described. In taking a foot-bath the patient should use a 
tub of sufficient size to enable him to place in it his feet and legs up to 
the knees; the water should be as hot as can be borne, and, as the feet 
become a little accustomed to the temperature, hotter water should be 
added; the immersion should continue fifteen or twenty minutes; dur¬ 
ing it, the patient, being in his night-clothes, should be well wrapped 
up in blankets, and at the close should be so transferred to the bed as 
not to get in any way chilled. After he has got to bed, and has been 
heavily covered with blankets, the patient should drink one or two 
tumblerfuls of a very hot and strong lemonade containing one, two, or 
three tablespoonfuls of whisky or brandy. 

I think the popular belief that after a sweat there is a greater lia¬ 
bility than usual to take cold is well founded: care must, therefore, be 
exercised to avoid any exposure for a day or two. Anointing the 
skin with oil of sweet almonds, or with some other equally bland fat, 
appears to have some power of preventing the deleterious effects of 
cold after sweating. 


FAMILY VI—EXPECTORANTS. 


These are medicines possessed of the power of modifying the secre¬ 
tions and thereby influencing the inflammatory conditions of the re¬ 
spiratory mucous membranes. There are various, and even opposing, 
methods in accordance with which drugs act upon the pulmonary sur¬ 
faces. In certain states of the latter, as in the fii’st stages of acute 
bronchitis, the irritation of the part is too great for secretion, the first 
stage of inflammation being, as is well known, connected with suspen¬ 
sion of function : in this condition the so-called sedative expectorants are 
indicated. These are remedies which lower arterial action: they are 
all nauseants, and the increase of bronchial secretion by them is analo¬ 
gous to that which they produce in the skin. In order to get their full 
effect, they must be given in nauseating doses; and if these are gradu¬ 
ally increased until emesis is induced, the fullest therapeutic influence 
will be obtained. There are other drugs which may be termed stimu¬ 
lating expectorants, and which act directly upon the bronchial mucous 
membrane, some of them perhaps increasing secretion, but most of 
them rather modifying it, and some of them even diminishing it, by 
toning up a relaxed, over-secreting mucous membrane. Some sub¬ 
stances which can hardly be called expectorants are nevertheless use¬ 
ful in bronchial diseases: thus, gallic acid will sometimes lessen the 
large quantities of mucus secreted in bronchorrlxcea ; or, when the mucus 
is tenacious in chronic bronchitis , alkalies may be of service by rendering 
the secretions less viscid, and thereby facilitating expectoration. 

In many cases of disease occurring in the very young and in the 
very old, mucus may so accumulate in the lungs, owing to the inability 
of the enfeebled powers to force it up, as seriously to embarrass, or 
even fatally compromit, respiration. Very frequently, in acute cases 
of this character, such as the suffocative catarrh of infants, mechanical 
emetics are of the greatest service; but in chronic cases they induce so 
much disturbance of digestion as to render their use dangerous, and 
alcohol, carbonate of ammonium, oil of garlic or of turpentine, and other 
drugs capable of increasing the bronchial muscular power or activity, 
have to be relied upon. 

Again, in certain conditions of the lungs, especially in chronic ca¬ 
tarrhal pneumonia , iodine and other alteratives are of great value in 
facilitating the absorption of exuded materials; yet these remedies can 
hardly be called expectorants. It may be affirmed that the value of 

759 





760 


LOCAL REMEDIES. 


true expectorants in ‘pneumonia of any variety is exceedingly prob¬ 
lematic, and, except it be the muriate of ammonia, they far more often 
do harm in the chronic varieties by deranging digestion than they do 
good by influencing the lung-tissue. 

There are several substances, chief among them being morphine, 
hyoscyamus, chloroform, and hydrocyanic acid, which have the power 
of allaying cough and lessening irritation by an anodyne action. In 
regard to morphine, its property of checking secretion should be borne 
in mind, but should not prevent its use. These narcotics are especially 
useful when the cough is disproportionate to the amount of inflam¬ 
mation. When large quantities of mucus are being secreted in debili¬ 
tated subjects, their use requires great caution, for fear of benumbing 
the nerves or nerve-centres and thereby increasing the danger of an 
accumulation of phlegm in the lungs. 

Among the respiratory narcotics may be considered Pyridin, one of 
the principles found in tobacco-smoke. Led by the relief sometimes 
afforded in asthma by the smoking of cigarettes, M. Germain See 
( Therap. Gaz., 1885) made a series of clinical studies which seem to 
show that pyridine is of great service in asthmatic complaints. As 
first manufactured by Merck, it is a colorless, peculiar-smelling fluid, 
easily soluble in water, boiling at 1061° C., on exposure to the air ab¬ 
sorbing water, and then boiling at a lower temperature. In using it a 
fluidrachm is evaporated in a small closed chamber, and the patient 
allowed to breathe the air twenty to thirty minutes, the process being 
repeated three times a day. According to the experiments of Silva 
(Lond. Med. Rec., Feb. 5, 1887), the inhalations of pyridin have the 
effect of diminishing the quantity of air respired in a fixed period, and 
of always causing abundant salivation, with coryza and general excite¬ 
ment. Dr. Joseph S. Neff (IV. Y. Med. Journ., March, 1886) states that 
the inhalations produce in the healthy adult flushing of the face and 
quickening of the pulse and respiration, but that in asthma the effect 
is to quiet the respiration and cause fall of the pulse to the normal rate, 
and to produce an irresistible desire to sleep. He confirms the value of 
pyridin in the treatment of asthma. 

Expectorants may be arranged under two heads,—the nauseant or 
sedative expectorants, and the stimulating expectorants; and the gen¬ 
eral proposition may be laid down that expectorants of the first class 
are to be used in the first stages of acute bronchitis, while expectorants 
of the second class are to be employed in the advanced stages or in the 
chronic varieties of the disease. As these diseased conditions gradu¬ 
ally merge into one another, so must the practitioner balance the in¬ 
gredients of his expectorant mixtures, adapting their relations to the 
individual case. 

The present seems a fitting place to say what is necessary in regard 
to the use of drugs by atomization. In this method of administration, 
a solution of the medicine employed is broken up by a mechanical con- 


EXPECTORANTS. 


761 


trivance into a fine spray and projected into the back of the mouth. 
There can be no doubt that when the operation is properly performed 
the spray reaches even the finest ramifications of the pulmonary 
bronchi. A discussion of this is at present scarcely necessary. Any 
reader having doubt upon the subject will find the evidence in the 
work of Dr. J. Solis Cohen ( Inhalation: its Therapeutics and Practice , 
Phila., 1867). 

The following rules should be attended to, to secure successful 
results: 

1. TJse the steam atomizers: all other forms of apparatus give 
irregular or too feeble currents, and should be discarded. 

2. See that the points of the atomizing tubes are sharp and clean, 
—not foul, cracked, or with their edges worn. 

3. See that the steam is generated equably and with sufficient force, 
and that the solution used is free from all solid particles, and, unless 
otherwise ordered, about the temperature of the body. 

4. Never allow inhalations when the patient is excited, directly after 
eating, or immediately after exercise, unless especial circumstances, as 
in haemoptysis, demand haste. 

5. Have the glass mouth-speculum inserted well into the mouth, and 
the line of its axis and of the propulsion of the spray coincident with 
that of the mouth. 

6. When the pharynx, or even the larynx only, is to be reached, the 
operation is very simple, and respiration should be natural; but when 
it is desired to make applications to the ultimate bronchi, the respira¬ 
tions should be regular, slow, and as deep and full as possible, the lungs 
being well emptied at expiration. 

7. Do not protract the sitting until the patient is fatigued. Five 
minutes is generally long enough to commence with. In haemoptysis, 
this rule may sometimes be departed from with advantage. 

8. Let the patient give his whole attention to the matter in hand. 

9. In chronic disease, one, two, or three inhalations a day are usually 
sufficient. In acute disease, they may be required much more often, 
as every hour in diphtheria. 

10. Never use atomization for the purpose of general medication: it 
is simply a method of applying substances locally to the respiratory 
organs. 

The substances used by atomization may be conveniently ai'ranged 
as follows: * 


* Attention has been called to the inhalation of fresh, almost nascent vapors of muriate 
of ammonia. By means of a very simple apparatus, air loaded with muriatic acid vapor is 
drawn at each inspiration through a weak water of ammonia, and of course reaches the lung 
saturated with the vapors of the muriate. Dr. Leberman {Brit, and For. Med.-Chir. Rev., 1874, 
i. 518) affirms that he has employed this with the happiest results in one hundred and two 
cases of granular sore throat, chronic bronchitis, asthma, whooping-cough, and even angina 
pectoris ! Most druggists, I believe, keep the inhalers. 



762 


LOCAL REMEDIES. 


Diluents. —The only diluent of any value is warm water. In acutely 
inflamed conditions of the mucous membrane , the very frequent appli¬ 
cation of water at about the temperature of 90° F. will often afford 
marked relief, especially in laryngitis. 

Astringents.— These are employed to arrest excessive secretion or 
hemorrhage. In their use, it must always be remembered that they 
are more or less irritant, and that while some persons bear them very 
well, in others they produce very harmful irritation; also, that the 
idiosyncrasies of patients vary, so that while one person will best bear a 
certain one of the astringents, a second may be less irritated by another 
drug. The rule is to try carefully until the pulmonary idiosyncrasies 
are known. In cases of excessive bronchial secretion , any irritation 
sufficiently severe to give origin to tightness in the chest, or to much 
coughing, calls for the withdrawal of the medicine. In hcemoptysis, a 
greater risk can be judiciously assumed. The astringent substances 
employed in this way are : First, tannic acid , one to twenty grains to 
the fluidounce of water. I have not used this; but it is said to be well 
adapted to cases of free secretion. Second, alum , varying in strength 
from a solution of five grains to the ounce to a saturated solution. This 
I have used with great satisfaction. In hceinoptysis, only the strongest 
preparation is of avail; in bronchorrhcea, a weak solution should be 
employed at first, and the strength increased pro re nata. One advan¬ 
tage this drug has over tannic acid is its compatibility with the sul¬ 
phate of morphine, which should always be added to its solution when 
any tendency to irritation exists. In chronic bronchitis with excessive 
expectoration, I have seen alum produce most gratifying results. 
Third, preparations of iron: of these the solution of the perchloride 
has been used in Great Britain and on the .Continent; but Monsel’s 
solution (. Liquor Ferri Subsulphatis) is much preferable, as even more 
powerfully styptic and less irritating. Ten drops of the solution may 
be added to the fluidounce of water and be used for the trial dose. If 
the lungs will bear it, and necessity exists for a stronger solution, the 
strength may be carefully increased up to half a fluidrachm to the 
ounce. Acetate of lead is at once astringent and sedative. It has been 
recommended by Beigel and by Fieber in the advanced stages of acute 
catarrhs, in the proportion of three to ten grains to the fluidounce. 

Narcotics.— When there is great laryngeal or even bronchial irrita¬ 
tion, especially in the laryngitis of advanced phthisis, half a grain of 
morphine, or a drachm of tincture of hyoscyamus, will often afford very 
great relief. It must not be forgotten that the constitutional effect of 
the narcotic may be produced in this way. 

Solvents. —As is well known, in certain respiratory affections it is 
very important to get rid of a false membrane, or exudation, which 


EXPECTORANTS. 


763 


appears upon the mucous surfaces. Some substances seem to exert at 
least a degree of solvent power upon this material. Of these, lime- 
water appears to be the most etfective and the least irritant. It should 
be used pure. (See article on Lime (post) ; also consult Meigs and 
Pepper, Diseases of Children , Phila., 1874, p. 680.) 

Alteratives. —In chronic bronchitis , and even in chronic catarrhal 
pneumonia , or phthisis, balsamic vapors have long been used, but atomi¬ 
zation is not necessary in their application. Muriate of ammonia may, 
however, be so applied: in chronic bronchial catarrh it is sometimes 
advantageous, and in acute laryngitis inhalations of a warm saturated 
solution of it are often very useful. In chronic laryngitis , nitrate of 
silver may be exhibited by atomization, but it is, I think, much better 
to apply it directly by means of the laryngoscope and the brush or 
probang. In cases of fetid expectoration, carbolic acid in weak solution 
(gtt. i-ii to f^i) may be used as an antiseptic and alterant. 

NAUSEATING EXPECTORANTS. 

The three nauseating expectorants are ipecacuanha, tartar emetic, 
and lobelia. As these substances are sufficiently discussed elsewhere in 
this work, it remains only to say a few words in regard to their com¬ 
parative use as expectorants. 

Lobelia is used only when the inflammatory action is complicated 
with a tendency to spasm of the bronchial muscles. It is too power¬ 
fully depressant to be given to children with safety. The best expec¬ 
torant preparation is the tincture (Tinctura Lobelice, LT.S.). The ordi¬ 
nary expectorant dose of this is twenty to thirty drops, usually given 
in combination every three hours. When a very decided impression is 
desired, as in some cases of asthma, one fluidrachm may be exhibited 
every two hours until vomiting is produced or relief obtained. Under 
these circumstances, the patient should be closely watched, as lobelia 
in these large doses sometimes causes very alarming symptoms. 

Ipecacuanha is the safest and most used, although perhaps the 
least powerful, of all the nauseating expectorants. It is the only one 
that should be given freely to children. In the early stages of all acute 
inflammatory conditions of the respiratory mucous membranes it is of 
great service. The preparation most generally used in acute bronchitis 
is the syrup, the dose of which is from twenty drops to a teaspoonful 
every two, three, or four hours, according to the exigencies of the case. 
Any of the other liquid preparations of ipecacuanha may be employed 
in a corresponding dose. The troches of ipecac (Trochisci Ipecacuanhce, 
U.S.) each contain about one-quarter of a grain of ipecac, and may be 
employed in catarrhal complaints. The troches of morphine and ipecac 


764 


LOCAL REMEDIES. 


(Trochisci Morphines et Ipecacuanha , TJ.S.) contain each the fortieth 
of a grain of sulphate of morphine and the twelfth of a grain of ipecac, 
and may be used when an anodyne effect is desirable. 

Tartar Emetic is much more powerful than ipecacuanha as a seda¬ 
tive and nauseant, and must be used with more care. It is the most 
efficient of all the sedative expectorants, and affords in cases of urgency 
a very efficacious, although a very disagreeable, method of putting an 
end to an attack of acute bronchitis. I have known of a public speaker, 
who had risen in the morning completely overwhelmed with bronchitis, 
enabled to deliver his evening speech by the judicious use of tartar 
emetic. To effect this rapid relief, one-twelfth of a grain of tartar 
emetic should be taken every ten or fifteen minutes until it induces 
profuse vomiting. After the nausea is past, the system may be toned 
up for exertion by a lunch of ale and oysters. Tartar emetic is a 
powerful remedy, and is especially injurious to young children, in whom 
it is very apt to induce collapse. It is therefore contra-indicated by 
infancy, as it also is by the existence of gastro-intestinal inflammation. 
The dose as an expectorant is from one-twelfth to one-quarter of a grain, 
repeated according to circumstances. 

GRINDELIA. U.S. 

This is the leaves and flowering tops of G-rindelia robusta, a plant 
inhabiting the extreme western portions of the United States. In 
commerce the whole herb, including the stems, roots, and floral heads, 
is employed. The taste is warmish, peculiar, and very persistent. It 
has been affirmed by Dr. Rademacher to contain an oil, a resin, and a 
crystalline alkaloid, but further chemical investigation of it is urgently 
required. 'When taken internally in sufficient dose it is said to produce 
a sense of warmth in the stomach, owing to its local stimulant influence. 

We are indebted to Dr. Buffington and Dr. V. B. Dobroklowski for 
what knowledge we have of the physiological action of Grindelia. 
Unfortunately, their results are known only through abstracts. (See 
Centralbl. f. Med. Wissens, xxiii., 1885; Amer. Journ. Med. Sci., Jan. 18, 
1886; Lond. Med. Hec., March, 1886.) The drug appears to have very 
feeble toxic powers, three drachms of the fluid extract being required 
to kill rabbits. So far as the nervous system is concerned, according 
to Dr. Buffington, grindelia first paralyzes the peripheral nerves of 
sensation, next the sensory side of the spinal cord, and finally involves 
the motor nerve-trunks and the motor side of the cord. The occurrence 
of narcosis with dilated pupils indicates that there is also an influence 
exerted upon the cerebrum. In warm-blooded animals, according to 
the same investigator, there is slowing of the action of the heart by 
stimulation of the inhibitory apparatus, and elevation of the blood- 
pressure by stimulation of the vaso-motor centre. The results achieved 
by Dobroklowski do not seem altogether to accord with these statements, 


EXPECTORANTS. 


765 


as he found that both small and large, but not toxic, doses, increased 
the pulse-rate as well as the arterial tension: after toxic doses both 
pulse-rate and arterial tension fell, the heart being finally arrested in 
diastole. These phenomena were not affected by isolation of the heart 
from the nervous system by the previous use of atropine or by vaso¬ 
motor paralysis through division of the spinal cord, and the isolated 
frog’s heart was arrested by the drug. Dr. Dobroklowski further found 
that the drug acts upon the motor nerves and the muscles. 

Therapeutics. —G-rindelia has not been employed for its effect upon 
the circulation, and in the doses used in medicine it appears to exert no 
distinct influence upon the heart or arteries. It has been largely used, 
often with alleged excellent results, in asthma, and in bronchitis, associ¬ 
ated with a tendency to bronchial spasm. It is probable that in these 
cases it not only has a relaxing influence, but also stimulates the mucous 
membrane, and even in chronic bronchitis, especially of the aged, it is 
said to do good. It has also been employed in whooping-cough. Its 
active principles are probably excreted by the kidneys: hence after 
large doses there are sometimes evidences of renal irritation, and in 
chronic catarrh of the bladder good has been effected by its stimulant 
influence upon the mucous membrane of the viscus. It has also been 
employed as a local application, with alleged good results, in vaginitis, 
applied either in the form of a poultice or in solution. The only prepa¬ 
ration for internal use is the fluid extract (Extractum Grindelice Fluidum ), 
of which the dose is twenty to sixty minims. The fumes of burning 
grindelia are also sometimes inhaled with alleged relief by asthmatics. 
The plant should be steeped in a solution of nitre, dried, and burnt 
upon a plate, or may be smoked in cigarettes or in a pipe. 

STIMULATING EXPECTORANTS. 

AMMONH CHLORIDUM—CHLORIDE OF AMMONIUM. U.S. 

(NH 3 HCI—NH 4 C1.) 

Chloride of Ammonium, Muriate of Ammonia, or Sal Ammoniac, is pre¬ 
pared by heating with chloride of sodium the sulphate of ammonium, 
which is obtained from gas-liquor by the addition of sulphuric acid. 
Gas-liquor is a water which has been used to wash ordinary burning-gas, 
and contains largely of the carbonate, hydrocyanate, hydrosulphate, and 
sulphate of ammonium. The sulphate of ammonium is not itself em¬ 
ployed as a medicine, but is officinal, because the other preparations 
of ammonia are made from it. 

Muriate of ammonia is a white, translucent, fibrous, and tough salt, 
free from odor, but having a sharp, saline taste. It occurs in large con¬ 
cavo-convex plates, dissolves in three parts of cold and in one part of 
boiling water, and at a red heat sublimes without decomposition. 

Physiological Action.— When applied in a solid form, or in a con¬ 
centrated solution, the chloride of ammonium acts as an irritant upon 


766 


LOCAL REMEDIES. 


raw surfaces and upon mucous membranes. This influence seems, how¬ 
ever, not to be sufficiently powerful to enable the drug in any dose to 
produce lethal poisoning: at least, Oesterlen ( Heilmittellehre , Tubingen, 
1851) states that one of his patients took two ounces of the salt with¬ 
out suffering any more sevei*e results than colicky pains and some 
diarrhoea. 

If some of the older experimenters are to be credited, its influence 
upon the lower animals is more powerful. In the experiments of Dr. 
Smith (quoted by Stille), two drachms of the salt applied to the 
wounded thigh of a dog caused death in from twelve to thirty-six 
hours, and, according to Orfila, the same quantity dissolved in two 
ounces of water and introduced into the stomach of a dog caused vio¬ 
lent convulsions, with great tetanic rigidity, and finally death. Arnold 
(Wibrner, Die Wirkungen der Arzneien und G-ifte , Munich, 1831, Bd. i. p. 
143) found that thirty grains will kill a rabbit in ten minutes. On 
the other hand, in the more recent studies of Dr. Babuteau (_Z7 Union 
Medicate, 1871, p. 330), half a drachm injected into the veins of a mod¬ 
erate-sized dog had no apparent effect, while one drachm only produced 
muscular weakness, deepening into temporary paralysis of the hind 
legs, vomiting without diarrhoea, and general prostration for four or 
five hours. 

The chief interest of the clinician in the physiological action of 
muriate of ammonia centres in its effects when given continuously for 
some time. The older writers upon the subject assert that its influence 
on the heart is a sedative one, but that it increases the capillary circu¬ 
lation (Sundelin, Heilmittellehre , Band i. p. 150, Berlin, 1853). This 
opinion appears to me to be founded chiefly upon speculation and in¬ 
ference, and not to have any sufficient basis. Whatever may be the 
action of very large amounts, I have never been able to perceive that 
muriate of ammonia given in ordinary doses has any decided influ¬ 
ence upon the circulation. According to Sundelin and other authori¬ 
ties, the drug when given freely and continuously produces a profound 
impression upon the blood itself, lessening its plasticity and impairing 
its constitution. One case of profound and otherwise inexplicable 
prostration and typhoid condition, which occurred in a patient who was 
taking nearly a half-ounce of muriate of ammonia per diem, has come 
under my own notice; and Dr. Isham reports ( Med. News , xl. 455) a 
case in which an eruption of bloody blebs, with hseraaturia, hemor¬ 
rhages from mucous membranes, and great prostration, was apparently 
produced by the prolonged use of the salt. The elaborate analyses of 
F. W. Bocker ( Beitrdge zur Heilkunde , Bd. ii. p. 170, Ckefeld, 1849), 
although somewhat discordant, indicate that sal ammoniac does im¬ 
poverish the blood, since in some instances there was a decided decrease 
in the solids. Arnold ( loc . cit.) also noticed that in dogs poisoned with 
muriate of ammonia the blood contained less than the normal per¬ 
centage of solids. In accord with this reputed action on the blood is 


EXPECTORA NTS. 


767 


the effect of the drug upon, the urinary secretion. In a very elaborate 
series of experiments, Bocker ( loc. cit ., p. 158) found that, given to a 
healthy man, sal ammoniac increased very notably all the solids of the 
urine, except the uric acid, which was very slightly diminished; and 
Rabuteau, in an investigation in which, by identity of diet, etc., all 
sources of fallacy were as far as possible excluded, found that the ex¬ 
cretion of urea was very decidedly increased. 

The opinion has long prevailed that the muriate of ammonia espe¬ 
cially affects the mucous membranes, and Bocker believes that in them 
it hastens very greatly the nutritive changes and the exfoliation of 
epithelium. Clinical experience has, I think, demonstrated that the 
drug does act especially upon the mucous membranes; although it is 
very difficult to bring forward any definite tangible proof of this. 

The muriate of ammonia, when ingested, probably enters into all 
the excretions, since Rabuteau {L' Union Med., t. xii. p. 329, 1871) has 
found it in the saliva. The same observer has shown that the ohief 
elimination takes place through the kidneys, since he found in the 
urine almost all of the salt that had been taken. 

Therapeutics.— In the last century chloride of ammonium was 
very extensively used in intermittent fever ; but at present the salt is 
rarely or never employed, although Aran ( Bulletin Therap ., t. xii. p. 
344) has attempted to revive the practice, and asserts that he has had 
very good effects resulting from it,—in thirteen cases of intermittent 
fever curing, by the exhibition of two drachms a day, seven at once, 
four after the second paroxysm, one after the third, and one after the 
fourth. The chief present use of the muriate of ammonia is as a 
remedy in acute and in chronic bronchitis: in the first variety of the 
disease the drug should not be exhibited in the first stages; but after 
active inflammatory action has been subdued by the sedative expecto¬ 
rants, it is very useful. It is very largely employed in the catarrhs of 
young children, and is often of great service. In Germany the remedy 
has been extensively exhibited in gastric and intestinal catarrhs. Dr. 
W. Stewart,* as the result of a large experience, highly commends its 
use in chronic torpor of the liver , chronic hepatitis , and hepatic abscess. 
In the first of these affections I have employed it to a limited extent, 
with very good effects. Dr. Stewart gives twenty grains of it three 
times a day, and continues its use for weeks or even months. 

In various neuralgias , especially in the ovarian variety, but to a less 
extent in migraine and other forms, sal ammoniac has been largely 
employed for the purpose of relieving pain. Thirty grains of it are 
given in combination with from two to five drops of tincture of aconite 
root, and the dose is repeated in half an hour, if necessary. 

Administration.— The usual dose of the muriate of ammonia in 


♦ Chloride of Ammonium, Rangoon, 1870; Madras Monthly Journ. Med. Set., Feb. 
and March, 1872; Indian Med. Gaz., Dec. 1872; Phila. Med. Times, viii. 316. 



768 


LOCAL REMEDIES. 


catarrh is from five to ten grains three or four times a day. This dose 
is given in a tablespoonful of water, to which, for the purpose of con¬ 
cealing the taste, from five to ten grains of liquorice may be added. 
The troches ( Trochisci Ammonii CMoridi , U.S.) contain two grains each, 
and are used as a local stimulant to the fauces and the epiglottis. 

SENEGA—SENEGA. U.S. 

The root of Polygala Senega, a small, herbaceous perennial, indige¬ 
nous to the Middle and Southern United States. The root is several 
inches long, very much contorted, of a peculiar feeble odor, and a taste 
at first sweetish but afterwards acrid. It is distinguished by a keel-like 
line, shorter than the root, and presenting the appearance as if a string 
were drawn tightly under the bark from end to end. Quevenne dis¬ 
covered in senega a peculiar principle which he named Polygalic Acid , 
although he thought that it was closely allied to saponin. According 
to Husemann ( Die Pflanzenstoffe , p. 751), the more recent researches 
of Bolley {Ann. Chem. Pharm ., xc., xci.) have shown that it is identical 
with saponin , a glucoside first found in the root of Saponaria officinalis, 
but now known to exist in a great many plants. It is a white, amor¬ 
phous powder, of a neutral reaction, odorless, but very irritating to the 
nostrils, and having an acrid, burning taste. It is very soluble in 
water, to which, even when in no greater quantity than one part in 
a thousand, it imparts the property of foaming like soap-suds, when 
shaken. 

Therapeutics. —Senega is chiefly used as a stimulant to the mucous 
membrane of the lungs in chronic bronchitis and in the very advanced 
stages of the acute disorder. It is believed to be one of the most 
stimulant substances of its class, and is therefore contra-indicated by 
acute pulmonary inflammation, and is indicated by a relaxed state of 
the bronchial mucous membranes. If its stimulant effect be modified 
by combination with tartar emetic, it may be given in acute bronchitis 
at an earlier stage than it could be used by itself. Senega is locally 
irritant, and, when administered in large doses, produces vomiting, 
which is probably reflex in its origin. In overdoses it not only vomits, 
but also purges : it is, however, never used for these purposes. Senega 
has been employed as an emmenagogue in amenorrhcea and as a diuretic 
in dropsy , but has achieved no permanent reputation in these disorders. 
The abstract {Abstractum Senegce , U.S.,—dose, five to ten grains) and 
the fluid extract {Extractum Senegce Fluidum, U.S.,—dose, ten to fif¬ 
teen drops) are officinal, but the syrup {Syrupus Senegce , U.S.,—dose, a 
fluidrachm) is usually employed. 

AMMONIACUM—AMMONIAC. U.S. 

The concrete juice of an umbelliferous plant, Dorema Am monia,cum, 
a native of Persia. It is said to exude from punctures made in the 


EXPECTORANTS. 


769 


plants, and also to be obtained by a process similar to that employed 
in the case of asafetida. It is a gum resin, containing a little volatile 
oil, and occurs in commerce as irregularly globular yellowish tears, 
from the size of a pin to that of a large chestnut, hard and brittle 
when cold, and breaking with a smooth resinous fracture; and in irreg¬ 
ular mottled masses, composed in part of tears, and containing many 
impurities. The odor is faint and disagreeable, the taste bitterish, 
sweetish, and somewhat acrid. 

Therapeutics. —The influence of ammoniac upon the general system 
is very slight. It is a local irritant, and therefore in large doses is 
capable of producing vomiting and purging. It was formerly em¬ 
ployed as a nervous stimulant, but its internal use is now restricted 
almost exclusively to chronic bronchitis with either deficient or excessive 
secretion. The dose of it is twenty to thirty grains; of the officinal 
mixture (Mistura Ammoniaci , U.S.), a tablespoonful. There are two 
officinal plasters of ammoniac: the Emplastrum Ammoniaci , which is 
used as a mild counter-irritant and as a local stimulant to promote the 
resolution of scrofulous tumors or enlarged joints, and the Emplastrum 
Ammoniaci cum Hydrargyro, which contains mercury and sulphur, and 
is employed as a local stimulant, alterative, and discutient in the same 
affections as the first-named plaster, and in syphilitic nodes and tumors: 
its external use is said to have caused salivation. 

SULPHURETTED HYDROGEN. 

As a sequence to the bacillus theory of phthisis, in July, 1880, Dr. 
Bergeon proposed before the French Academy of Science a method of 
treating tuberculosis, the central idea of which is the injection of sul¬ 
phuretted hydrogen gas diluted with pure carbonic acid into the large 
intestine. The apparatus employed consists of a large caoutchouc bag, 
filled with carbonic acid gas, connected with a Woulffe's bottle, which 
is in turn united to a tube, the other end of which is inserted into the 
rectum of the patient, so that by compressing the bag the carbonic 
acid is forced to bubble through a solution of sulphuretted hydrogen, 
natural or artificial, and pass into the intestine. Bergeon preferred 
natural sulphur-water, but artificial solutions have been used much 
more extensively. In the Hopital Cochin the following solutions 
were employed, fifteen cubic centimetres of No. 1 being used at one 
seance. 

Solution No. 1. — Sulphide of sodium, pure, ten parts by weight; 
distilled water, enough to make one hundred parts by weight. 

One cubic centimetre of this liquid disengages exactly ten cubic 
centimetres of sulphuretted hydrogen, when there is added to it one 
cubic centimetre of the following solution (No. 2): 

Solution No. 2.—Acid tartaric, twenty-five parts by weight; acid 
salicylic, one part by weight; distilled water, one hundred parts by 
weight. 


49 


770 


LOCAL REMEDIES. 


In the Philadelphia Hospital from three to five pints of carbonic 
acid were forced through a solution of ten grains each of the chloride 
and the sulphide of sodium,—sulphuretted hydrogen being formed by 
the reaction between the sulphide of calcium and the carbonic acid : 
thus, MaS + C0 2 -f H 2 0 = NaC0 3 -(- H 2 S. It is plain that the 
amount of sulphuretted hydrogen received by the patient must be very 
variable even with the Ilopital Cochin solution, while the plan adopted 
in Philadelphia is still more unsatisfactory. According to M. Morell, 
twenty-five cubic centimetres is the dose of the gas. In over-amounts 
sulphuretted hydrogen acts as a deadly poison, and in the hospital of 
the University of Pennsylvania a quart of a mixture containing equal 
quantities of carbonic acid and sulphuretted hydrogen injected into 
the rectum caused in three minutes unconsciousness, with scarcely 
perceptible respirations at the rate of one hundred a minute, and im¬ 
perceptible pulse, symptoms subsiding in fifteen minutes under artificial 
respiration and other treatment. 

There is no proof that sulphuretted hydrogen is poisonous to the 
tubercle-bacilli, and, after an extraordinary but very temporary popu¬ 
larity, the Bergeon treatment of phthisis has fallen into desuetude. 
My own experience, however, has led me to the very positive belief 
that sulphuretted hydrogen may be very useful in the treatment of 
various catarrhs , and that when in phthisis expectoration is very free 
it may do much good, not by curing the original pathological process, 
but by alleviating the catarrh caused by this process. In chronic bron¬ 
chitis with expectoration, in catarrhal pneumonias , and in asthma with 
much bronchial inflammation, sulphuretted hydrogen is a valuable 
remedy. My own experience is also quite positive that when admin¬ 
istered persistently for months it may be of service in chronic gout. 
It is probably also useful in many cases of skin-disease. It is in these 
affections of the mucous membranes and of the skin, and in the gouty 
diathesis, that the so-called sulphur springs have been used from time 
immemorial by innumerable patients. The method of administration 
employed by Bergeon is barbarous and possesses no advantages what¬ 
ever. Under it, it is impossible to determine exactly how much sul¬ 
phuretted hydrogen is exhibited, while in most cases the colon is more 
sensitive than is the stomach to the local action of the drua:. A much 
better method is the exhibition of sulphuretted hydrogen by the mouth, 
either in the form of the natural sulphur-waters, or, as I have em¬ 
ployed it, by means of water saturated with sulphuretted hydrogen 
and carbonic acid gas. This water is very readily prepared by a small 
apparatus, is not objected to by most patients after the first day or two 
of its taking, and usually does not disagree with the stomach; although 
there are cases in which it causes so much abdominal disturbance that 
its use has to be abandoned. The dose of the saturated solution is two 
to four ounces three or four times a day. After the larger doses the 
odor of the gas upon the breath becomes very perceptible. 


EXPECTORA NTS. 


771 


BENZOINUM—BENZOIN. U.S. 

The concrete juice of Styrax Benzoin, a large tree, native of Peru. 
The drug is said to be obtained by incising the tree and allowing the 
juice to harden as it exudes. The finest specimens of benzoin consist 
of tears agglutinated together; the poorest, of brown or blackish 
masses without tears. The fracture is resinous, the surface of the 
tears smooth and whitish, the odor fragrant, the taste at first very 
slight, afterwards somewhat acrid. The chief constituents of benzoin 
are resin and benzoic acid; cinnamic acid is also frequently present, 
and is said to be especially found in the white tears. 

Benzoic Acid (Acidum Benzoicum, U.S.) is obtained by sublimation 
of gum benzoin. As thus prepared, it is in white feathery crystals, of 
a silky lustre and a fragrant vanilla-like odor, due to the presence of a 
volatile oil, the pure acid being inodorous. The taste is warm, acrid, 
peculiar. Benzoic acid melts at 250° F., and volatilizes without change; 
is soluble in two hundred parts of cold and in twenty-four parts of 
boiling water; also soluble in alcohol, fixed oil, and alkaline solutions. 
It is a feeble acid, but forms neutral salts with the alkalies. Benzoic 
acid is widely distributed through the vegetable kingdom, constituting 
the peculiar principle of all true balsams, and is occasionally present 
in the urine of grass-eating animals. It is a normal constituent of 
castor, and has been detected by Seligsohn (Chemische Centralblatt, 
1861) in the suprarenal capsules of an ox. It is used considerably in 
the arts, and for this purpose is prepared from the allied hippurie acid 
of horse-urine, and also, it is said, from naphthalen. 

Physiological Action. —Locally applied, benzoic acid is a decided 
irritant, and its vapors, when inhaled, produce bronchial catarrh. 

Our knowledge of the action of benzoic acid upon man and the 
higher animals is very limited. In ordinary therapeutic doses it exerts 
no perceptible influence upon man, except, it may be, in the production 
of gastric irritation, with consequent nausea and vomiting. Thus, 
Schreiber took in two days about half an ounce of the acid, and ex¬ 
perienced only a feeling of abdominal warmth, spreading over the whole 
body, and accompanied by an increase of the pulse-rate amounting to 
thirty beats per minute, by increased secretion and excretion of phlegm, 
with slight disturbance of digestion. 

Very few experiments with benzoic acid upon the lower mammals 
have been reported. W. Grube ( Centralbl. fur Chirurg., 1876, p. 777) 
states that in massive doses (1 to 5766 of the animal’s weight) it pro¬ 
duces intoxication, with disturbance of circulation and respiration, and 
paralysis of the hind feet, and that the antipyretic influence of benzoic 
acid is greater than that of salicylic acid. 

Especial interest attaches to the elimination of benzoic acid, be¬ 
cause, as was first discovered in dogs by Wohler, and afterwards in 
man by Ure, it appears in the urine, united with nitrogenous atoms, 


772 


LOCAL REMEDIES. 


as hippuric acid.* Kuhne and Ilallwachs thought that the conversion 
occurred in the liver; but the more recent researches of Meissner and 
Shepard ( Untersuchungen uber das Entstehen der Hippursaure, Hanover, 
1866) appear to show that it really takes place in the kidneys. Cer¬ 
tainly it does not happen in the intestines or in the blood, since after 
the exhibition of large doses of benzoic acid it alone can be detected 
in the blood ; and after the administration to rabbits by the mouth of 
large amounts of hippuric acid, only traces of the latter, with large 
quantities of benzoic acid, can be found in the blood, although the hip¬ 
puric acid appears in the urine ;f further, moderate amounts of hip- 
13 uric acid injected into the blood cause severe symptoms of poisoning, 
which is not true of benzoic acid. When benzoic acid is injected freely 
into the blood, a portion escapes through the kidneys unchanged. J G. 
Bunge and C. Schmiedeberg have also found that in the dog with renal 
arteries tied no conversion of benzoic into hippuric acid occurs, but 
that tying of the ureters does not interfere with the change. They 
have also succeeded in converting benzoic into hippuric acid by passing 
blood containing benzoic acid, with or without glycocoll, slowly through 
the kidneys, removed from the body directly after death. From some 
of their experiments it would seem that the blood-corpuscles play an 
important role in the process, as when serum freed from blood-cor¬ 
puscles was used, at most only a trace of hippuric acid was formed. 
According to Meissner and Shepard, sometimes the benzoic acid is con¬ 
verted into succinic instead of hippuric acid in man, and in chickens it is 
habitually changed into two new products, one of which is nitrogenous. 
It has not yet been clearly made out where the nitrogen necessary 
for the formation of the hippuric acid is obtained. In the elaborate 
experiments of Carl Virchow ( Zeitschr. f. Phys. Chem., vi.), benzoate of 
sodium caused a decided increase of the nitrogenous elimination from 
the kidneys; but the testimony as to the effect of the ingestion of ben¬ 
zoic acid upon the urea and uric acid of the urine is singularly contra¬ 
dictory. Thus, Ure (Medico-Chirurg. Trans., 1841, xxix. 30), Leroy 
d’Etiolles (quoted by Stille), and Debouy (quoted by Stille) affirm 
that the uric acid is very much diminished or altogether absent, while 
Garrod ( Memoirs of the Chem. Soc., i., 1842, and Lancet , Hov. 1844) and 
Keller (Ann. der Chem. und Pharm., xliii., 1842) assert that its quantity 
remains normal. Again, Garrod affirms that the urea is very much 
diminished in quantity, while Keller and Meissner and Shepard (loc. 
cit .) declare that it is not affected. The only logical conclusion would 

* Gusseron found hippuric acid in the urine of a new-born child when benzoic acid had 
been given to the mother just before the birth ( Hoffmann und Schwalbe’s Jahresb., 1879, 283). 

f This alleged conversion of hippuric acid is not thoroughly established, and has given 
rise to much discussion. For a general summary and latest information, see paper by Van 
de Velde and Stockvis, Arch. f. Exper. Path. u. Pharm., xvii. 189. 

X According to the experiments of Th. Weyl and B. von Anrep, if benzoic acid be given 
to man or animals in a febrile state a much larger proportion of it than usual is eliminated 
unchanged ( Hoffmann und Schwalbe’s Jahresb., 1881, 447). 



EXPECTORANTS. 


773 


seem to be that the effect of benzoic acid upon the urine is variable. 
All authorities appear to agree, however, in asserting that the acidity 
is increased.* 

In April, 1872, Dougall {Med. Times and Gaz., i., 1872) announced 
that benzoic acid is an active antiseptic. Since that time, numerous ex¬ 
periments have been made by E. Salkowski {Berlin. Klin. Wochens ., 1875, 
297), Grube {Centralbl. f. Chirurg., 1876, 778), Bucholtz {Archiv f. Ex- 
perim. Pathol, und Pharm., Bd. iv.), and Fleck {Benzoesaure, etc., Munich, 
1875), with the unanimous result of ascribing to benzoic acid a first 
rank in destroying bacteria and preventing putrefaction. In most of 
these investigations benzoic acid was found to be much more active 
than salicylic acid. Bucholtz found that 0.02 per cent, of benzoic acid 
had a very perceptible effect upon the development of bacteria, and 
0.1 per cent, inhibited their growth entirely; also that the benzoate of 
sodium was no less powerful than the pure acid. 

Therapeutics. —Benzoic acid, or gum benzoin, was formerly very 
freely exhibited in chronic bronchial catarrh as a stimulant expectorant; 
at present it is not much employed. The chief use of it is in urinary 
affections. Dr. Ure first suggested and commended its employment in 
uric acid gravel and calculus , because, as he thought, it diminishes the 
excretion of uric acid; but its possession of this power has been strenu¬ 
ously denied. Mo less an authority, however, than Dr. Golding Birdf 
asserts that clinical experience has shown its value in uric acid diathesis. 
In the phosphatic urine of vesical catarrh , benzoic acid may be employed 
with much advantage. By rendering the urine more acid it increases 
its power of dissolving the phosphates, and at the same time it exerts 
a stimulant action upon the mucous membrane of the bladder. Dr. 
Lamaire affirms that benzoic acid (fifteen grains in twenty-four hours) 
given along with cannabis indica acts most happily in acute gonorrhoea 
{Phila. Med. Times , iv. 638). 

Since the discovery of the antizymotic power of benzoic acid, it has 
been used to some extent in Germany as a remedy in diphtheria , ery¬ 
sipelas , and allied diseases, with asserted good results. Two or three 
drachms of the benzoate of sodium are given during the twenty-four 
hours. Professor Senator, of Berlin, states that, administered in suffi¬ 
cient dose, benzoic acid is as much of a specific in acute rheumatism 
as is salicylic acid. He gives it in daily doses of from two to three 
drachms, and states that larger amounts may be employed with im- 


* Dr. Garrod, having discovered that the hippurates have the power, when added to blood- 
serum containing urates, of causing the disappearance of the uric acid, has suggested their 
use in practical medicine in uric acid diathesis. He gives of the hippurate of sodium ten 
grains three times a day. It may well be combined with lithium or potassium salts. 

f Urinary Deposits, Philadelphia, 1859, p. 160. Dr. Bird states that he has found the 
following formula of great service in chronic uric acid gravel: Sodii carbonatis, 3* S3 > acidi 

benzoici, gr. xl.; sodii phosphatis, £>iii ; aquae ferventis, f^iv; solve et adde aquae cinnamomi, 
f^viiss; tincturae hyoscyami, f^iv. S.—Two tablespoonfuls three times a day. 



774 


LOCAL REMEDIES. 


punity; the benzoate of sodium is preferred to the pure acid, as of 
easier solubility ( Allgem. Wien. Med. Zeitung , 1878, xxiii.). 

Benzoic acid has the property of preventing animal fats from be¬ 
coming rancid, and is therefore much used as an addition to ointments. 
Moreover, it exerts a peculiar, often very beneficial, stimulant action 
upon the skin, and is very useful in such conditions as chapped hands, 
lips,* or nipples, and even in fissure of the anus. 

There would seem to be no doubt that benzoic acid may be substi¬ 
tuted for carbolic or salicylic acid in antiseptic surgery. Under the 
name of balsamum traumaticum , a preparation practically the same as 
the compound tincture of balsam was formerly much used as a vul¬ 
nerary. The practice has gone out of vogue j but the discoveries con¬ 
cerning antisepsis and the excellent results obtained by Mr. Bryant 
(.Lancet , 1876, ii. 747) show that it was well founded. Mr. Bryant 
simply covers the wound in compound fractures and other severe in¬ 
juries with lint thoroughly saturated with the compound tincture of 
benzoin, and maintains absolute quiet, with non-removal of the dressing, 
for some days. His results appear to challenge those obtained by the 
most complicated antiseptic surgery (see also Lancet , 1877, i. 671). 

Administration. —The dose of benzoic acid is from ten to thirty 
grains. Gum benzoin is never used itself, but is exhibited in the form 
of the tincture {Tinctura Benzoini —1 to 5, U.S.),—dose, fjss to f3i; and 
of the compound tincture ( Tinctura Benzoini Composite, U.S.), used in 
chronic bronchial catarrh,—dose, fji to f3ii. Adeps Benzoinatus, U.S., 
contains only enough of the benzoin to preserve the lard, and is em¬ 
ployed as the basis of ointments. 

Balsamum Peruvianum, or Balsam of Peru, is obtained from Myro- 
spermum Peruiferum, a tree of Central America, by making incisions 
in places which have been previously beaten with clubs, slightly burn¬ 
ing them, catching the juice in old rags, and finally boiling these in 
water and skimming off 1 the balsam as it rises to the surface. This 
balsam is a viscid, honey-like, fragrant, brownish fluid, of a warm, 
bitterish taste. According to Fremy, it contains not benzoic, but cin¬ 
namic acid. It has been used in chronic catarrhs of the respiratory 
and the genito-urinary system, in doses of half a fluidrachm. 

Balsamum Tolutanum, or Balsam of Tolu, is obtained from a tree 
very closely allied to that which yields the balsam of Peru, if indeed it 
be not identical with it. The incisions, however, are not burnt, and 
the juice is simply caught in vessels. Balsam of Tolu is at first a thick, 
viscid fluid, but by time it is converted into a hard, translucent, resinous 
solid. Its odor is highly fragrant, and its taste vanilla-like. It contains 
cinnamic acid and a volatile oil, and its medical properties are the same 

* Professor Still6 commends a mixture of one part of the compound tincture of benzoin 
and four parts of glycerin. 



r 


EXPECTORANTS. 775 

as those of the balsam of Peru. On account, however, of its grateful 
taste, it is preferred to the latter, and is very much used to flavor medi¬ 
cines, especially cough-mixtures. In large doses (gr. xx to gr. xxx 
every three hours) it may be of some value in chronic catarrh, but as 
generally used its preparations are simply agreeable vehicles. The 
dose of the tincture (Tinctura Tolutana —1 to 10, U.S.) is one-half to 
one fluidrachm; of the much more frequently used syrup (Syrupus 
Tolutanus, U.S.), half a fluidounce. 

Allium, U.S., or English Garlic , the clove of Allium sativum, con¬ 
tains a volatile oil, which is a stimulant in small doses to digestion, 
and is also a stimulating expectorant often of very great service in 
certain stages of bronchitis. It is in lingering, deep-seated “ colds ” that 
I have derived especial benefit from its use. It is also very valuable 
in the acute bronchitis of infants, when the powers of the system begin 
to give out. The oil of garlic is further believed to have the ability 
to stimulate the expulsive function of the small bronchial tubes, and is 
certainly a powerful rubefacient and a decided nervous stimulant. For 
these reasons, garlic poultices are a favorite application in the acute 
suffocative catarrh of infants, and are not rarely applied to the spine, 
legs, and feet in general infantile convulsions. They are made by simply 
reducing the garlic to a pulp by pounding. When a continuous appli¬ 
cation is desirable to the delicate skin of an infant, as in catarrh, it is 
generally necessary to reduce their strength with flaxseed meal. 

Scilla, or Squill , is one of the most used of the stimulating expec¬ 
torants, coming especially into play in the advanced stages of ordinary 
bronchitis. The syrup (Syrupus Scillce , U.S.) is the favorite expectorant 
preparation. As it contains acetic acid, it is incompatible with the 
carbonate of ammonium. The Compound Syrup of Squill (Syrupus 
Scillce Compositus, U.S.: squill, senega, aa one hundred and twenty 
parts; tartar emetic, three parts to two thousand parts) contains one 
grain of tartar emetic to the ounce, and is therefore sedative to the 
circulation, although stimulant to the bronchial mucous membrane. It 
is, of course, in large doses a powerful emetic; and, under the name of 
Coxe's Hive Syrup, it is very frequently used in the domestic treatment 
of croup. The dose of the simple syrup is one-half to one fluidrachm; 
of the compound, twenty to forty drops; as an emetic to children, 
ten drops to a fluidrachm, according to age, repeated every twenty 
minutes until it operates. 

Pix Liquida. — Tar is a black semi-liquid substance, of peculiar odor 
and taste, obtained by the destructive distillation of various species of 
pine. The tar used in this country is almost exclusively the product 
of the Pinus palustris of North Carolina and other of the Southern 
States. In composition it is very complex, containing pyroligneous 


776 


LOCAL REMEDIES. 


acid, creasote, empyreumatic oil, and a number of more or less peculiar 
principles. When distilled, it yields an oily liquid, known as oil of tar , 
and a solid, black residue, pitch. It is freely soluble in alcohol, ether, 
and the fixed and volatile oils, and also to a slight extent in water. 

Physiological Action.— As tar contains a notable proportion of 
creasote, if taken in sufficient quantity it is capable of exerting the 
peculiar influence of that agent upon the system. But creasote is not 
the only active principle in it: hence tar differs from that drug in acting 
more than it does upon the mucous membranes. That tar is capable of 
acting as a poison is shown by the case reported by Taylor ( Principles 
and Practice of Medical Jurisprudence , 2d ed., vol. i. p. 334), in which 
death resulted in a man from taking by mistake the oil of tar. To 
cause death, tar itself would have to be ingested in enormous quantity, 
since a sailor (according to Stille) is said to have recovered after taking 
between a pint and a quart of it. 

Applied to any part, tar acts as a very decided stimulant. 

Therapeutics.— Tar is used internally almost solely as a stimulant 
expectorant in the advanced stages of obstinate acute bronchitis , or in 
chronic bronchitis. Its chief use in medicine is in chronic diseases of 
the skin, as a stimulant application in the form of the officinal ointment 
( Unguentum Picis Liquidce , U.S.,—equal parts). In many cases this is 
too severe, and the strength must be reduced. Professor Hebra states, 
in his work on diseases of the skin, that if it be applied too freely 
enough of the tar may be absorbed to darken the color of the fasces 
and the urine, and even to cause gastric irritation and black vomit. 
Tar Water may be used internally, in doses of half a fluidounce to one 
fluidounce; a better preparation is the Syrup of Tar (Syrupus Picis 
Liquidce —6 to 100, U.S.),—dose, half a fluidounce. 

The use of Eucalyptus and of Turpentine as expectorants has 
been discussed in the articles upon those subjects in the earlier portions 
of this book. 

Terebene is a clear, colorless liquid, insoluble in water, isomeric 
with turpentine, and of a peculiar odor, somewhat resembling that of 
freshly-sawn pine wood. It is prepared by adding drop by drop to any 
convenient quantity of oil of turpentine five per cent, of its weight 
of U.S.P. sulphuric acid. The mixture must be kept cool, allowed to 
stand in a porcelain capsule so as to be exposed thoroughly to the air 
for twelve or eighteen hours, and distilled at a temperature not above 
160° C. 

Terebene is a valuable stimulant expectorant, first recommended 
by Dr. William Murrell {Brit. Med. Journ., Dec. 1885) in that form of 
chronic bronchitis often known as winter cough. It is very useful not 
only in cases of chronic bronchitis, but also in the acute disease after 
the earlier stages have passed by. As an expectorant it is nearly 


EXPECTORANTS. 


777 


equivalent to the oil of eucalyptus, but is, perhaps, a little more stimu¬ 
lating. It probably exerts upon other mucous membranes the same 
action that it has upon that of the lungs, and has been employed with 
asserted good results in dyspepsia, especially in the flatulent intestinal 
variety, and may be used in chronic or subacute inflammations of the 
genito-urinary tract. Its action upon the genei’al system has not, that 
I am aware of, been investigated, but probably resembles that of oil of 
turpentine. It cannot be given in watery solution, and the method 
sometimes practised of dropping it on sugar is improper, on account of 
its being apt to make with sugar a tough, insoluble mass. It should 
be administered in emulsion, or preferably in capsules. From forty to 
sixty minims of it may be given to the adult in the course of twenty- 
four hours, and increased if necessary. It has also been used by Dr. 
Murrell by atomization with asserted good results. 


FAMILY VU—EMMEN - AGO GrUES. 


Emmenaqogues are medicines which are employed to promote the 
menstrual flux. As the stoppage, scantiness, or non-appearance of this 
secretion arises from very different causes, and as these causes are of 
diverse or even opposite natures, and may often be removed by drugs, 
it is obvious that very many remedies of very different character are 
indirect emmenagogues. Thus, amenorrhoea may depend upon plethora, 
or it may be the result of anaemia; and while in the one case depletory 
medicines are indicated, in the other case tonics are no less essential. 
Besides these indirect emmenagogues, there are other substances which 
appear to act directly as stimulants to the uterine mucous membrane; 
and indeed it is probable that many of the indirect emmenagogues 
possess more or less of this power. The emmenagogues may be con¬ 
veniently arranged in three groups,—the tonic emmenagogues, the pur¬ 
gative emmenagogues, and the stimulant emmenagogues. 

TONIC EMMENAGOGUES. 

Iron is the most prominent member of this section of the emmena¬ 
gogues. By far the larger number of cases of amenorrhoea are asso¬ 
ciated with, if not dependent upon, anaemia, and are benefited by the 
use of iron. It should be given in full tonic doses until the anaemia is 
relieved or the powerlessness of the remedy to effect such change is 
demonstrated. It is very rarely proper to rely solely upon the iron, 
which in the great majority of instances should be combined with more 
decidedly active emmenagogues. 

Myrrh has some reputation as a tonic emmenagogue, but, as it is 
always employed in combination with other more active medicines of 
its class, the role it plays is somewhat uncertain. It should be used 
only in atonic uterine conditions, and is said to be especially valuable 
when chronic pulmonary complications exist. The preparations of it 
most used in amenorrhoea are the compound pills of iron, the compound 
mixture of iron, and the pills of aloes and myrrh. 

PURGATIVE EMMENAGOGUES. 

Aloes is believed by some to act as an emmenagogue solely by virtue 
of its stimulant action upon the rectum, but it very probably directly 
778 



EMMENA GOO UES. 


779 


affects the uterine mucous membrane. Be this as it may, it is a stimu¬ 
lant emmenagogue, especially useful when atonic amenorrhoea exists with 
constipation. Ordinarily it should be given in repeated doses (three 
times a day) of such size as will produce daily one or two soft, semi¬ 
liquid stools. At the menstrual period advantage may be sometimes 
derived from the administration of a full purgative dose. It is almost 
always given in combination, especially with iron, whose tendency to 
constipation it obviates. In 'plethoric amenorrhoea , when torpidity of the 
bowels is present, salines, and not aloetic purgatives, should be employed. 

Black Helleboke has been used by some as a purgative emmena¬ 
gogue, but is now very rarely if ever employed. From twenty drops 
to a fluidrachm of the tincture may be given three times a day. 

STIMULATING EMMENAGOGUES. 

SABINA—SA VINE. U.S. 

The dried tops of Juniperus Sabina, a juniper, native of the south 
of Europe and the Levant, but very similar to our native species, the 
Juniperus Virginiana, or red cedar. The active principle is a pale or 
dark yellow, when highly rectified colorless, volatile oil ( Oleum Sabince, 
U.S.), which has a strong terebinthinate odor and burning taste. 

The oil of savine is a powerful local stimulant, causing burning and 
redness when applied to the skin, and is capable of producing fatal 
gastro-intestinal inflammation. Taken internally in minute doses, its 
effects are confined to a sense of warmth, with perhaps some ill feel¬ 
ing in the stomach, and slight acceleration of the pulse. After larger 
amounts, the arterial excitement is more pronounced, and is accom¬ 
panied by an increased frequency of urination, and sometimes, also, 
by an actually increased flow of urine. The symptoms induced by 
poisonous doses are: severe abdominal pain; incessant vomiting and 
bloody purging; diminution or even suppression of the urine, which is 
often albuminous and bloody; disordered respiration; symptoms of 
disturbed innervation, such as unconsciousness, stertorous breathing, 
convulsions or convulsive tremblings; the scene closing by death in 
collapse. In pregnant females, abortion, accompanied by violent flood¬ 
ing, almost always occurs before the fatal issue. After death, signs of 
gastro-intestinal inflammation are generally present, but in some in 
stances these are wanting, and in one case reported by Dr. Letheby 
{London Lancet , 1845) pulmonary apoplexy and congestion of the brain 
were the chief lesions. Taken in small, repeated doses, savine is a pow¬ 
erful stimulant to the uterine system, and may be used as such in atonic 
amenorrhoea. Its powers in menorrhagia dependent upon a relaxed state 
of the uterine tissues are even more pronounced. Its use as an aborti- 
facient is accompanied by the gravest dangers to life. In uterine dis¬ 
ease of a sthenic type savine is strongly contra-indicated. The dose of 


780 


LOCAL REMEDIES. 


the oil (Oleum Sabince, U.S.), the only preparation which should be 
used, is from five to ten drops, repeated every three or four hours. 

RUT A—RUE. 

The leaves of Ruta graveolens, or common garden rue, an under¬ 
shrub of the south of Europe. Rue has a strong peculiar odor, a warm, 
bitter, acrid taste, and is dependent for its medical properties upon a 
peculiar volatile oil, although it also contains a crystalline neutral body, 
Rutin. 

The influence of rue upon the system is similar to, but less decided 
than, that of savine. Locally it is an irritant, producing, when applied 
to the skin persistently or in a concentrated form, such as the oil, burn¬ 
ing, redness, and vesication. According to M. Helie, taken internally, 
in large doses, it causes violent gastric pains, excessive and sometimes 
bloody vomiting, profuse salivation and swelling of the tongue, great 
prostration, confusion of mind, and convulsive twitchings, with, in 
pregnant women, abortion. Rue has been, and probably still is, em¬ 
ployed in Europe for the production of criminal abortion, and, although 
its use for this purpose certainly endangers life, I have met with no 
record of a fatal case. Indeed, the only death from rue that I am 
cognizant of occurred in a man weakened by dysentery (case, Dr. 
G. F. Cooper, Med. Examiner , N. S., ix. 720). Like savine, it is em¬ 
ployed both in amenorrhoea and in menorrhagia when dependent upon 
uterine atony; and especial advantage has been claimed for the combi¬ 
nation of it with savine. Owing to the aromatic properties of its oil, 
it has been used somewhat as a carminative. The oil, the only proper 
preparation, may be used in doses of from three to six drops every 
three or four hours. 

PETROSELINUM—PARSLEY. 

The root of Petroselinum sativum, or common parsley. It contains 
a peculiar, non-nitrogenous, liquid, neutral principle, Apiol, which re¬ 
sembles somewhat the fixed oils, but is not saponifiable; a glucoside, 
Apiin , and a volatile oil. 

Physiological Action. —The volatile oil of parsley has probably 
the same physiological and therapeutic value as the more ordinary 
essential oils, and according to Mitscherlich very large quantities of it 
(half an ounce) will produce death in the rabbit, largely, no doubt, 
owing to its local irritant action. The chief interest of parsley to the 
physician centres in apiol. According to the discoverers of this prin¬ 
ciple, MM. Joret and Homolle ( Journal de Pharmacie , 3e serie, xxviii. 
219), one gramme of it will produce in man a cerebral excitation very 
similar to that induced by coffee, without other symptoms. In doses 
of from two to four grammes it causes a species of intoxication, with 
vertigo, ringing in the ears, and severe frontal headache,—a group of 
symptoms very similar to those seen in cinchonization. 


EM MEN A GOG UES. 


781 


Therapeutics. —Apiol was introduced by its discoverers as a remedy 
in intermittent fever, over which, they asserted, it exercised a control 
secondary only to that of quinine. A commission of the Paris Society 
of Pharmacy reported that it would cure about half the cases of quo¬ 
tidian and tertian, but was powerless against the quartan; also, that a 
return of the paroxysm was more common after apiol than after quinine. 
Clinical experience subsequent to these experiments has demonstrated 
that the drug has some power over malarial disease., but is very in¬ 
ferior to quinine. Joret and Homolle also employed the drug in inter¬ 
mittent neuralgia , and in amenorrhoea as well as in dysmenorrhoea. Joret 
(.Bxdletin Therap ., Feb. 1860) has recommended apiol very highly in 
the last two atfections, and his results have been confirmed by Marotte 
(Ibid., t. lvi., 1863) and other writers. When there was very decided 
plethora, the apiol was thought by Marotte not to be so efficacious as 
at other times. In any case of amenorrhoea dependent upon or asso¬ 
ciated with anaemia or other systemic vice, the continuous administra¬ 
tion of iron, tonics, or other suitable medicines must not be neglected. 
The apiol is given not between the menstrual periods, but just before 
the latter. Joret and Homolle believe that small doses (three grains 
twice a day) of it should be exhibited for the week preceding the 
expected return of menstruation. If any symptoms of the menstrual 
molimen appear, fifteen grains of it may be administered in the course 
of a few hours; or they may be given daily for two or three days at 
the expected time. In intermittent fever, the same quantity may be 
exhibited four or five hours before the expected paroxysm. On account 
of its exceedingly disagreeable taste, apiol is always administered in 
capsules, one of which, as imported from France, usually contains the 
fourth of a gramme (gr. 3.9). 

Permanganate of Potassium, originally recommended by Pro¬ 
fessor Sydney Ringer as an emmenagogue, has been very highly com¬ 
mended by Dr. Fordyce Barker and other physicians (see Therap. 
Gaz ., vols. ii. and iii.). According to Dr. Barker, the permanganate is 
not to be employed when menstruation has been arrested by grave con¬ 
stitutional or local disease, or suddenly by cold, moral shock, or acute 
disease. Professor Ringer says that the permanganate has no power 
of originating uterine contractions, but other clinicians attribute to it 
abortifacient properties, and cases are reported in which abortion has 
followed its administration (see J. L. Watkins, Therap. Gaz., vol. ii., 
S. B. Sperry, Ibid., vol. iii.). 

Therapeutic doses of the permanganate must be entirely decomposed 
in a very short time after they reach the stomach, so that any action 
which the drug exerts upon the general system is due to the oxide of 
manganese; indeed, the ordinary black oxide of manganese is affirmed 
by various practitioners to be as active an emmenagogue as is the per¬ 
manganate. I have employed these agents to a limited extent in func- 


782 


LOCAL REMEDIES. 


tional amenorrhcea, sometimes with, sometimes without, success. The 
only difference which I have been able to perceive in their action is 
that the permanganate is the more irritant to the stomach. The dose 
of either preparation may be set down as one or two grains,—always 
administered after meals, in order to avoid, as far as possible, gastric 
irritation. Cases of severe gastritis produced by the permanganate 
have been reported ( Therap. Gnz ., vol. iii., 1887). 

Cantharides is a very decided uterine stimulant, and is much used 
as an ingredient of emmenagogue mixtures. From three to five drops 
of the tincture may be given three times a day; if no unpleasant 
symptoms arise, the dose may be cautiously increased to six drops, 
the production of strangury being, of course, sedulously avoided. 

Guaiac, as an emmenagogue, is much less stimulating than can¬ 
tharides, and is believed by some to be especially useful in rheumatic 
dysmenorrhcea. In this affection, full doses of the ammoniated tincture 
should be given. The following formula, adapted from one of Pro¬ 
fessor Dewees, and known as Dewees's Emmenagogue Mixture , I rely 
upon almost exclusively in the treatment of simple atonic amenorrhoea. 
The proportion of the various ingredients should be varied to suit the 
exigencies of individual cases. Thus, the amount of iron should be 
altered according to the extent of the anaemia; of the aloes, according 
to the state of the bowels; of the cantharides, according to the sus¬ 
ceptibility of the urinary organs: 

R Tincturae ferri chloridi, f5iii; tincturae cantharidis, f3i; tincturae 
aloes, fgss; tincturae guaiaci ammoniatae, fjiss; syrupi, q. s. ad fgvi. 
S.—Tablespoonful three times a day. 

Tanacetum, U.S.—The common tansy of the gardens, in the form 
of decoction, or of its volatile oil, is sometimes used as a stimulant 
emmenagogue or for the purpose of producing abortion, but is a very 
unsafe remedy. When taken in sufficient amount it causes abdominal 
pain, vomiting, loss of consciousness, and violent epileptiform convul¬ 
sions.* The minimum fatal dose of the oil of tansy which will cause 
death is not known, but in two cases (Cincinnati Lancet and Clinic , 
1881) a teaspoonful of the oil produced violent epileptiform convul¬ 
sions, and the same amount is said to have caused death ( U.S. Disp.). 
Recovery has occurred after one and a half fluidrachms ( Lond. Med. 
Dec., 1882, p. 48). The action of the oil upon the lower animals has 


* For references to fatal cases, most of which have occurred in the United States, see 
U.S. Dispensatory, also Professor Guillery ( loc. cit.). Professor Guillery believes that the 
symptoms caused by the oil and by tansy tea are different. In a case of poisoning by the 
leaves, however, reported in the Nashville Med. and Surg. Journ., 1879, xxiii., the symptoms 
were those alleged to be characteristic of oil-poisoning; and the oil probably is the only active 
principle of the drug. 



EM MEN A GOG UES. 


783 


been studied by Professor Guillery ( Bull. Acad. Boy. Med. de Bruxelles , 
1878, xii.). In frogs the most important effects which he found it to pro¬ 
duce were paralysis of the peripheral endings of the motor nerves, with 
early appearance of post-mortem rigidity; and paralysis of the vaso¬ 
motor centre of the medulla, and of the inhibitory cardiac apparatus, 
with at last paralysis of the heart itself. In warm-blooded animals the 
oil produced symptoms precisely similar to those it causes in man. 
After section of the spinal cord the convulsions did not occur in the 
hind legs: they are therefore of cerebral origin. The arterial pressure 
was not affected until death was at hand: so that it is evident that the 
drug has little action upon the heart. 

Oil of Pennyroyal.— The oil of Mentha pidegium is sometimes used 
as a stimulating emmenagogue in domestic practice, but has very little 
power. Two fluidrachms taken by a young woman produced vertigo, 
faintness, muscular weakness, frequent feeble pulse, cold skin, and cold 
extremities (Dr. C. A. Bryce, Southern Clinic , vi. 323). 


FAMILY YHL—OXYTOOICS. 


Oxttocics are those remedies which are employed during or directly 
after parturition, to increase the uterine action. It has been asserted 
that sulphate of quinine is a member of this class; but, as this sub¬ 
ject has been already fully discussed, no more will be here said about 
it. The power of stimulating the uterine pains has been claimed for 
various drugs, but at present there is only one substance except quinine 
really used for this purpose; and, instead of discussing under the gen¬ 
eral heading the indications for and the dangers attending the employ¬ 
ment of oxytocics, I shall do it in the article upon Ergot. 

ERGOTA—ERGOT. U.S. 

• Ergot is a blackish body, one to two inches in length, irregularly 
cylindrical, grooved along one side, and very generally curved, which 
is composed of very thick walled microscopic cells, containing oil-drops 
but no starch. Various opinions have been advanced in regard to the 
nature of this body; but as by the researches of Tulasne (Ann. des 
Scien. Nat., Botanique, 3e serie, t. xx., 1853) it has been determined ex¬ 
actly what it is, I shall not occupy space with a discussion of the older 
views. Among the lowest of vegetable organisms, and distinguished 
from all other plants by the absence of chlorophyl, are the fungi. There 
are in most cases two distinct states or stages in the life of a fungus: in 
the first of these, the vegetable period, it exists as a mycelium , a usually 
filamentous mass or flocculus, whose sole function is to grow and in¬ 
crease ; in the second stage the thallus , or ordinary fungus or mushroom, 
is formed, and to it is assigned the function of developing reproductive 
bodies, after whose maturing it perishes. Between these stages there 
is in some fungi an intermediate one, in which the plant exists as a 
sclerotium. The genus Claviceps comprises a number of parasitic fungi, 
which develop in the pistils of the various species of Graminese. The 
officinal ergot is the sclerotium of the Claviceps (C. purpurea, Tulasne) 
which infests the grain of Secale cereale, or rye. The first appear¬ 
ance of the fungus is during the earliest life of the pistil, at the base 
of which there arises a minute flocculent mass of mycelial filaments. 
These filaments, continually growing and invading all parts of the 
tissue of the pistil, at last form of it an irregular whitish body, at the 
base of which after a time appears a dark-colored body, the sclerotium, 
which continues to grow, lifting up the diseased and withering mass 
784 



OXYTOCICS. 


785 


formed out of the original pistil, and finally developing into a perfect 
ergot. If a fresh, living ergot be placed in a damp, warm place, after 
a time little cracks will appear in its surface, and through these cracks 
little round bodies will project, and finally be raised up on stalks and 
constitute perfect thalli,—minute fungi, which finally produce spores. 

Ergot is an exceedingly complex substance, containing nearly thirty- 
five per cent. (Legrip) of an inert fixed oil, and, in minute amount, a 
peculiar ammoniacal base, which was stated by Winckler to be pro- 
pylamin, but appears really to be trimethylamin. What its activity de¬ 
pends upon is unsettled, every chemist who has studied it arriving at a 
diverse result. Three alkaloids have been described from it,—two non- 
crystallizable, Ecboline and Ergotine, by Winckler (Amer. Journ. Pharm., 
May, 1864), and one crystallizable, Ergotinine, by Tanret (Bull. Therap., 
xciii. 231) ; three acids, Ergotic, Phosphoric (Levi, Lo Sperimentale , Aug. 
1875), and Sclerotinic (Dragendorff and Podwissotzky, Arch, fur Exper. 
Path, und Pharmak., vi. 192) ; also various other substances of even 
still more doubtful nature.* As the watery extract ( Ergotin , so called) 
contains all the active ingredients of ergot, it may be used as the 
nearest approach to the active principle at our command. 

Physiological Action. —In ordinary therapeutic doses, ergot causes 
no immediate perceptible symptoms; but when a sufficient amount is 
exhibited, it acts as a poison both upon man and upon animals. Before 
considering its action when given in small quantity, I shall discuss its 
toxic effects. 

According to Diez (quoted by Stille), the principal effects of poi¬ 
sonous doses of ergot are in the lower animals profuse salivation, 
vomiting, dilatation of the pupils, hurried breathing, frequent pulse, 
cries, trembling, staggering, paraplegia, sometimes diarrhoea, sometimes 
constipation, prostration, urgent thirst, convulsions,f and death. Mr. 


* Besides the papers quoted, the reader desirous of following up the subject should look at 
Haudelin (Schmidt’s Jahrbiicher, Bd. civ.; T. C. Hermann ( Buchner’s Repertoriumfur Pharm., 
1871; Bucheim (Arch.f. Exper. Pathol, u. Pharm., Bd. iii.; also Berlin. Klin. Wochenschr., 
1876, p. 309; Salkowski ( Berl. Klin. Wochenschr., 1876, p. 22); Zweifel ( Arch.f. Exper. Path, 
u. Pharm., Bd. iv.) 

f Pereira (Materia Medica, 3d American edition, vol. ii. p. 137), on the authority of 
Phoebus, states that in the experiments of Diez convulsions were not present. 

Sclerotinic Acid. —Dr. Max Stumpf (Deutsch. Arch.f. Klin. Med., xxiv. 417) asserts that 
in various hemorrhages he has obtained from the hypodermic use of sclerotinic acid most 
happy results, but Dr. Rennerb (Centralbl. fiir Gynacologie, 1879) has met with nothing but 
failure. Dr. W. Nikitin ( Wurzburger Phys. Med. Verhandl., xiii.) has studied the physiological 
action of the acid upon frogs, cats, and rabbits. I have seen the report only in abstract, but 
it is stated that the fatal dose for rabbits was fifteen grains, that directly after the injection 
the bodily temperature fell from 1° to 3°, and that there was a progressive lowering of mus¬ 
cular power and arterial pressure, and, finally, death from failure of respiration. The paralysis 
was found to be spinal, and when pregnancy existed contractions of the gravid womb were 
produced. On the other hand, a series of experiments at the laboratory of the University of 
Pennsylvania, made by Dr. Chas. M. Seltzer with imported sclerotinic acid, showed that this 
specimen at least did not at all represent ergot, and at present it does not seem probable that 
sclerotinic acid will prove of practical value. In an elaborate research (Du Bois Reymond’s 

50 



786 


LOCAL REMEDIES. 


S. A. "Wright, in a series of experiments ( Edinb. Med. and Surg. Journ., 
Oct. 1839, vol. lii.), noted, when the medicine was given by the mouth, 
symptoms similar to those just spoken of: the paralysis was much 
more marked than were the spasms. Late in the poisoning, the heart’s 
action became irregular and intermittent, and the pulsations, which 
had been rapid, grew slow and feeble. In some cases the special senses 
seemed to be destroyed, and coldness of the surface was a very promi¬ 
nent symptom. Mr. Wright also injected a strong infusion of the 
drug directly into the torrent of the circulation. Death was in some 
cases produced in nine minutes, the symptoms being immediate dilata¬ 
tion of the pupils, great increase in the rate of the cardiac pulsations, 
paralysis, and convulsions. When the fatal result was not brought 
about in so short a time, great anaesthesia of the surface was noted a 
considerable time before death; coldness of the surface and paralysis 
of the special senses were also present in some cases. In Dr. Kersch’s 
experiments ( Betz's Memorabilien, vol. xviii.* *) the concentrated infusion 
was injected into the jugular vein; the coldness of the surface was 
especially noted, and also great muscular rigidity. IJpon rabbits, ac¬ 
cording to the researches of Wright, ergot acts very feebly. In birds, 
as represented by chickens, turkeys, and pigeons, it causes symptoms 
analogous to those produced in mammals, as is testified to by Tessier 
and by Gross, both quoted by Stille, and by Bonjean ( Traite de VErgot 
de Seigle, Paris, 1845). Enormous doses of ergot are required to pro¬ 
duce toxic symptoms in animals, since in one of Wright’s experiments 
an amount equivalent to two drachms for every pound weight of the 
dog failed to kill. 

Upon man the toxic influence of ergot is also very slight, and, al¬ 
though I have given the fluid extract in ounce doses, I have never seen 
it cause any distinct symptoms.f Fatal abortion has several times been 
produced by ergot; but I know of only two instances of decided poison¬ 
ing in a non-pregnant person. In the first cases ( U. S. Dispensatory') 


Archiv, 1S84, 434) upon the activities of the various derivatives from ergot, M. Marckwald found 
that the ergotine preparations (Ergotinum Citricum of Gehe, Ergotinum Solution of Bombelon) 
raise the arterial pressure, while sclerotinic acid depresses it, and ergotin (aqueous extract) first 
raises, then depresses, then raises it; also that the ergotin and sclerotinic acid act violently 
upon the uterus, while the ergotine preparations do not influence the organ. Dr. P. Robert 
claims to have obtained from ergot two new acids and one alkaloid, the process for the prep¬ 
aration of which may be found in Pharm. Centralhalle, Dec. 25, 1884. Ergotinic acid is 
affirmed to be the principal constituent of sclerotinic acid and an important constituent of 
the original ergotine of Bonjean. In full doses it is stated to act as a paralyzant to the spinal 
cord, but to be without influence upon the uterus. Sphacelinic acid is said to produce gan¬ 
grene, while cornutine, the alkaloid, causes in dogs tetanic stiffness, passing into cramps and 
epileptiform convulsions. 

* Unfortunately, I have not had access to Kersch’s paper, and know it only by abstracts 
in The Medical Times of Canada, vol. i., and Schmidt’s Jahrbiicher, Bd. clx. p. 120. 

f For cases, see Neubert, Journ. fur Pharmacodynamik, 1860, Bd. ii. p. 483, also, same 
case, Richter, Caspar’s Vierteljahrschrift, Bd. xx. p. 177; Tardieu, Ann, d’Hyg., 1855, vol. 
i.; Toledo Med. and Surg. Journ., July, 1878. 



OXYTOCIC'S. 


787 


gastric irritation, thirst, diarrhoea, burning pain in the feet, and con¬ 
vulsions are said to have preceded death. In the second case (Dr. Gr. 
S. Oldright, Canada Med. Journ ., 1870, p. 404), two hours after taking 
the drug (amount not stated) there were developed tingling in the 
fingers and feet, cramps in the legs, arms, and chest, with dizziness and 
weakness; the pupils were dilated, the pulse was very small, and a feel¬ 
ing of coldness was complained of. These symptoms were relieved by 
the administration of stimulants and the use of external heat; after a 
time they recurred with greater violence; finally, under the reinstitu¬ 
tion of the measures previously employed, the face became intensely 
congested and purplish red, pain in the head was felt, the patient 
seemed much excited,* and convulsions were feared, but did not occur; 
there was some diarrhoea, with dark-gray stools. In the case recorded 
by Heubert ( loc . cit .), the great coldness of the surface was especially 
noted; and as this symptom was very prominent in the case recorded 
in the Toledo Medical and Surgical Journal , and has been so commonly 
remarked in ergotized animals, it probably is characteristic of poison¬ 
ing by the drug. Dr. Davidson reports a case with fluid blood, jaun¬ 
dice, and universal hemorrhages, attributed with doubtful correctness 
to poisoning by ergot ( London Lancet , 1882, ii. 526). 

The above summary of the general symptoms caused by poisonous 
doses of ergot shows that the phenomena are mainly paralytic in their 
nature; but, although an enormous amount has been written about the 
drug, we have very little knowledge as to the immediate causes of the 
paralysis. Since both Wright (loc. cit., pp. 320, 321) and Kdhler have 
found that the voluntary muscles are not affected by ergot, it would 
seem that the nervous system must bear the brunt of the poison. 
Eugene Haudelin is said to have shown that the peripheral nerves are 
not affected,f and the experiments of Kohler have confirmed this so 
far as concerns the motor nerves and the watery extract of ergot. He 
found, however, that those portions of the drug not soluble in water 
appeared to increase the excitability of the peripheral efferent nerves, 
and that upon the peripheral sensory nerves both portions of the ergot 
acted as a feeble depressant. On the whole, it is probable that the 
chief action of the drug is upon the nerve-centres. 

The chief interest to the therapeutist in regard to the physiological 
action of ergot centres upon its influence on the circulation, especially 
on the blood-vessels, and upon its action on the impregnated uterus. I 
shall discuss these points seriatim. Before doing so, it would be, per¬ 
haps, best to speak of the chronic poisoning by ergot; but, as any 
deductions from the symptoms of ergotism as to the physiological 
action of the drug would be at best only inferences, I shall defer the 
consideration of the subject to the section on toxicology. 


* These symptoms were very probably caused by the large quantities of aloohol taken, 
f Inaug. Dissert., Dorpat, 1871 ; abstracted in Schmidt’s Jahrbilcher, Bd. civ. p. 142. 



788 


LOCAL REMEDIES. 


Action on the circulation. —Although the heart is profoundly affected 
in acute poisoning by ergot, yet death is probably not due to this cause, 
since Wright (loc. cit ., p. 320) found that after death, even though the 
heart was quiet, it commenced to beat as soon as the congestion was 
relieved by an incision, and continued to pulsate for fifteen minutes. 

One of the earliest careful cardiac studies of ergot is that of P. 
Eberty (abstracted, Schmidt's Jahrbucher , Bd. clviii. p. 127). He found 
that in the frog after the injection of a gramme of ergotin the heart 
suffers diastolic arrest and is unable to respond to stimuli. It is incon¬ 
ceivable that this can be due to other than a direct action of the drug 
upon the cardiac muscle; yet Eberty seems to believe it is caused by 
an influence exerted through the pneumogastrics, and it is said that 
after division of these nerves even very great quantities of ergotin are 
powerless to produce cardiac arrest. 

In man, full doses of ergot unquestionably diminish the frequency 
of the pulse, since the phenomenon has been independently noted by 
Parola, Gibbon, Arnal, Hardy, Beatty (all quoted by Professor Stille), 
and by Professors Bailly and See ( Bulletin Therap ., t. lxxviii. p. 435); 
but the method in which this reduction is brought about is uncertain. 
The amount of the reduction varies from ten to thirty-five beats per 
minute; but very rarely is the pulse reduced below sixty even by the 
largest doses. According to Eberty’s experiments, therapeutic doses 
of the drug produce in mammals, as in man, slowing of the heart’s 
beat. It was found that in frogs the pulsations of the heart were still 
affected after destruction of the medulla, but that in mammals, after 
paralysis of the peripheral vagi by atropine, ergot was powerless to alter 
the cardiac rhythm. These experiments, if correct, appear to prove 
that ergot acts as a stimulant to the peripheral cardiac nerves, and that 
the reduction of the number of beats is due to this, and is independent 
of the nerve-centres. Boreischa has noticed that toxic doses quicken 
the heart’s action, and that under these circumstances galvanization of 
the par vagum has little or no effect upon the heart. It would seem, 
therefore, as if the drug first stimulated and then paralyzed the periph¬ 
eral pneumogastrics. 

As early as 1827, M. Courhant advanced the opinion that ergot pro¬ 
duces a spasm of the blood-vessels ; but, although his theory was very 
generally adopted, only within a very few years has any earnest at¬ 
tempt been made to prove or disprove its correctness. In 1870, Dr. 
Ch. L. Holmes ( Archives de Physiol ., t. iii., 1870) found that when the 
blood-vessels of the frog’s web were watched under the microscope and 
the animal poisoned either with the aqueous extract of ergot or with 
the powdered drug, the vessels, both venous and arterial, could be seen 
to undergo a very great contraction. Dr. A. Wernich ( Virchow's 
Archiv, 1872, Bd. lvi. p. 510) observed that when rabbits in which the 
arteries of the thigh, back, pia mater, etc., were exposed, received full 
doses of ergot, these arteries could be seen to undergo a very remark- 


OXYTOCICS. 


789 


able diminution in their calibre. These observations have been con¬ 
firmed by other observers, among whom may be mentioned Vogt, Dr. 
S. Kersch ( loc. cit.), Max Schuller ( Berliner Klin. Wochenschr., 1874, p. 
305), and Boldt ( Schmidt's Jahrbucher , March, 1872). The latter ob¬ 
server also affirms that there ran through the ergotized capillaries 
wave-like, peristaltic spasms. Patrick Nicol and J. Mossop (Brit, and 
For. Medico-Chir. Rev ., vol. 1., 1872) have noted with the ophthalmo¬ 
scope the contraction of the retinal vessels after the exhibition of ergot 
in man. 

If general vaso-motor spasm be produced by ergot, unless the heart’s 
action be greatly weakened by the drug there must be a very decided 
rise in the arterial pressure. Dr. Ch. L. Holmes (loc. cit.) first showed 
that when the aqueous extract is injected directly into the jugular vein 
of the dog, immediate, rapid, and very decided depression of the arte¬ 
rial pressure occurs, with violent cries and efforts on the part of the 
dog, followed by a period of quiet and a rise of the arterial pressure 
above the normal point. As Kohler and Eberty ( Virchow's Archiv, Bd. 
lx. p. 384) and myself have all found that ergotin (Bonjean’s) raises 
the arterial pressure enormously in frogs and mammals, the fact must 
be accepted as proved. 

Dr. Holmes tried the effect of the injection of the ergot after sec¬ 
tion of the cardiac nerves, but obtained results so varying and contra¬ 
dictory that he could come to no other conclusion than that the alter¬ 
ations of the arterial pressure produced by ergot are not dependent 
upon its cardiac action. In the absence of details of these experiments, 
we can but accept this conclusion. 

The unexpected result in the investigation of Dr. Holmes was the 
primary depression of the arterial pressure, a depression which at first 
sight seems incompatible with the idea that ergot contracts the vessels. 
It is, of course, possible that the fall of pressure may be due to an in¬ 
tense action of the drug upon the heart; but Dr. Holmes, in order to 
explain it, propounds a theory which is very plausible, but which he 
certainly does not prove to be true. His idea is that the first fall of 
the arterial pressure is due to a spasm of the pulmonic capillaries, 
hindering the blood in its passage to the left heart, and thereby causing 
venous repletion and arterial depletion. It is to be remembei*ed that 
he injected the ergot directly into the jugular vein, so that the whole 
force of the remedy fell directly upon the pulmonic circulation. It is 
evident that this matters very little if ergot produces vaso-motor spasm 
only through an influence upon the nerve-centres, but that it does make 
a material difference if the contraction of the vessels be the result of a 
local action. Holmes asserts that after section of a sympathetic nerve 
and injection of the ergot the vessels supplied by the divided nerve can 
be seen to contract; and Wernich confirms this observation. If ergot 
does thus cause vaso-motor spasm, it is plain that in Dr. Holmes’s ex¬ 
periments this spasm must have been very intense in the lungs before 


790 


LOCAL REMEDIES. 


the systemic capillaries were affected. Our investigator proved by ex¬ 
periment what a priori seems necessarily true, that if blood be prevented 
from passing freely to the lungs the arterial pressure falls very greatly. 
In this connection it is worthy of notice that the period of arterial de¬ 
pression following the injection of the drug into the jugular vein was 
very brief. In the only experiment detailed in full by Dr. Holmes, 
the pressure began to rise in three minutes after the completion of the 
injection; in five minutes it was nearly normal, and in eleven min¬ 
utes it was above the normal point. If the asserted facts are all true, 
the theory of Dr. Holmes is plausible. It is, however, very doubtful 
whether the ergotic spasm is local in its origin. Evidence derived 
from judging by the eye as to whether a vessel does or does not con¬ 
tract must be taken cum grano salis, and the observations of Holmes, 
of Wernich, and of J. H. Peton ( De VAction de VErgot, Paris, 1878) are 
directly contradicted by the apparently careful and elaborate experi¬ 
ments of Dr. Paul Yogt ( Berlin. Klin. Wochenschr., 1869, Ho. xii.), in 
which the dilated vessels of the ear of a rabbit whose cervical ganglion 
had been extirpated could not be made to contract by ergot.* 

The results obtained by P. Eberty ( Inaug. Dissert., Halle, 1873) are 
in accord with those of Yogt, and disagree with those of Dr. Holmes, 
especially in their bearing upon the question whether the contraction 
of the arteries is centric or peripheric in its origin. He finds that the 
arterial pressure rises directly and enormously after the injection of 
ergotin. This rise, which he acknowledges to be chiefly due to the 
contraction of the vessels, occurs in the veins as well as in the arteries, 
and in the frog as well as in the dog and the rabbit. According to his 
experiments, it must be, at least in the batrachian, centric, since in the 
frog it does not take place after destruction of the medulla. He also 
found that after the inhalation of nitrite of amyl the ergot caused rise 
of the arterial pressure. It is a fair inference that if the vaso-motor 
spasm be centric in the frog it is also so in the mammal. 

In an especial investigation of the subject ( Phila. Med. Times,v ol. iv.) 
I found that ergotin injected into a vein does, as Holmes states, produce 
in the mammal an immediate fall of the arterial pressure, which is 
shortly followed by an enormous rise. I also found that division of the 


* In a series of experiments made by Professor S. Ringer and Dr. H. Sainsbury (Brit. 
Med. Journ., Jan. 1884) upon tortoises according to the method of Qaskell (see Digitalis, p. 
353), the addition of ergotin greatly slowed the rate of flow through the arterioles. 

These results certainly appear to be contrary to the previous drift of our evidence in 
showing that ergot acts locally upon the vessels. It was found, however, that the addition 
of ergotin to the saline solution used had no distinct effect until there was ten per cent, of the 
extract in solution. Ten per cent, of ergotin is enough very seriously to influence the viscidity 
of the saline solution, and it is probable that the slowing effect of the ergotin was the result 
of altered physical conditions,—a conclusion which is corroborated by the fact that the records 
clearly show complete loss of vitality in all parts of the tortoise experimented with, a loss of 
vitality which in all probability was shared by the arteries. Certainly these experiments can¬ 
not be accepted as valid in contradiction of the older results. 



OXYTOCICS. 


791 


cord, i.e., vaso-motor paralysis, does in dogs prevent the rise of the 
pressure. It must, therefore, be considered proved that moderate doses 
of ergot cause a rise of the arterial pressure by stimulating the vaso-motor 
centre; and that the first fall of pressure is due to a direct action on the 
cardiac muscle, upon which the ergotin is at once precipitated when 
thrown into the jugular vein, is demonstrated by the facts that the fall 
does not occur when the drug is introduced gradually into the circulation 
by hypodermic injection, and that the drug is a poison to the cardiac 
muscle, as was shown in my experiments as well as in those of Eberty. 

Haudelin is stated to have found that the arterial pressure falls after 
the exhibition of the poison. Brown-Sequard has insisted ( Archives de 
Physiologie, 1870, t. iii. p. 434) that in ergotic poisoning there are two 
periods,—first, vaso-motor spasm, and secondly, vaso-motor paralysis; 
and Haudelin noted a fall of arterial pressure after toxic doses. Dr. Bo- 
reischa ( Arbeiten Pharm. Laborat. Moskau, i. 55) also, in a number of ex¬ 
periments, using Bonjean’s ergotin, found a very decided fall of pressure 
produced by the drug. In none of these experiments was there any 
rise of pressure at all: either the ergotin used was not equivalent to 
that employed by Holmes and myself, or else the result obtained was 
dependent upon the use of very large doses. In a series of experiments, 
Boreischa found that the fall of pressure after section of the spinal 
cord high up was proportionately not nearly so great as in the normal 
animal. This indicates that the fall of pressure was due to vaso-motor 
palsy. It would seem, therefore, that the conclusions of Brown-Sequard 
are correct, and that decidedly toxic doses of ergot lower the arterial press¬ 
ure, by depressing both the heart and the vaso-motor centres. 

Action on the intestines. —The fibres in the coats of the blood-vessels 
are certainly not the only non-striated muscles upon which ergot acts: 
indeed, the probabilities are strong that the drug influences muscular 
fibre of this character wherever it exists in the body. There is con¬ 
siderable evidence to show that it causes increased intestinal peristalsis. 
In Dr. Wright’s experiments ( loc. cit ., p. 320) the intestines were found 
in very active peristalsis at the post-mortem examination of the poisoned 
animal. Dr. Wernich ( Virchow's Archiv , 1872, Bd. lvi. p. 515) noticed 
that very violent peristaltic movements followed the injection of ergot, 
as was seen not only in rabbits whose abdomens were opened, but in 
some cases even through the uninjured walls; and Haudelin has con¬ 
firmed his observations. 

Uterus. —Upon the uterus of parturient women ergot exerts a very 
pronounced and fixed influence, increasing the length and force of the 
pains, and, if it be given in sufficient dose, causing after a time violent 
tetanic cramp of the whole organ. The drug certainly acts in this re¬ 
spect upon the lower animals as it does upon man, since Youatt states 
that in a large experience, both with monogastric animals and with 
ruminants, he has never known the drug to fail in its action on the 
uterus of the parturient female. 


792 


LOCAL REMEDIES. 


The action of ergot in producing contraction in the impregnated 
but not parturient womb is by no means so constant. Upon animals, 
Dr. Wright found it to fail in all of a number of trials, as did also Bon- 
jean in a single experiment. On the other hand, Diez (Stille, Therapeu¬ 
tics , 2d ed., vol. ii. p. 585), Oslere (Ibid.), and Percy and Laurent (Ibid.) 
found it to cause abortion in guinea-pigs, sows, rabbits, cows, and cats; 
and M. Bodin has reported an epidemic of abortion occurring among 
cows near Trois Croix, which be attributes to feeding upon ergotized 
grasses (Journal des Connaissances Med., 1842). The evidence of those 
who have used ergot for the induction of premature labor in woman 
tallies very closely with that which is brought forward in regard to the 
lower animals. As the matter is so settled, I shall not enter into an elabo¬ 
rate discussion of the effects of ergot upon pregnant women. To show 
that the fungus very often will act as an abortifacient, it is only neces¬ 
sary to quote Professor Eamsbotham, who states (Obstetric Medicine, 
Phila., 1860, p. 318) that he has made a “great number of trials,” and 
found that “ expulsive action soon followed its exhibition, with very few 
exceptions.” It cannot be gainsaid, however, that very often the drug 
has failed: sometimes, no doubt, because of poor quality or because 
given in insufficient dose, yet sufficiently often to show that its aborti¬ 
facient action is uncertain.* 

Whether the uterine disturbance is of centric origin, or is due to a 
direct action of the drug upon the uterus and its nerve-fibres, is unde¬ 
cided, although the drift of the present evidence is towards a peripheral 
action. Dr. Wernich, in two experiments, found that no vermicular 
movements were produced in the unimpregnated womb by ergot after 
section of the spinal cord; but in one of these experiments the animal 
was so feeble as to destroy any possible force the result might have, 
and I do not think much weight is to be attached to the evidence. On 
the other hand, Boreischa, in several experiments, succeeded in pro¬ 
ducing violent uterine movements after dividing all the nervous con¬ 
nections of the organ. 

Therapeutics. —As a therapeutic agent, ergot is employed both by 
the obstetrician and by the physician; and I shall consider these uses 
of it separately. 

Owing to the power that ergot possesses of intensifying labor-pains, 
it has long been used in uterine inertia during parturition. Indeed, it 
was for this purpose that the drug was first employed in medicine, and 
thereby acquired the name of pulvis parturiens. The literature of the 
subject is immense, and all imaginable opinions as to the effects of the 
drug when given in labor, and as to the advisability of its employment, 
have been advanced; but, without discussing these, I shall here simply 
point out the clearly-established rules for its use, and the clinically- 


* For a more elaborate setting-forth of the matter, the reader may consult Professor Tay¬ 
lor’s Medical Jurisprudence, 2d ed., 1873, vol. ii. p. 193. 



OXYTOCICS. 


793 


determined dangers and advantages of its employment. If ergot be 
given in very small doses during labor, the natural pains are simply in¬ 
tensified ; but if the dose be large enough to have a decided effect, their 
character is altered: they become not only more severe but much more 
prolonged than normal, and finally the intervals of relaxation appear 
to be completely abolished and the intermittent expulsive efforts are 
changed into one violent, continuous strain. It is evident that, if the 
resistance be sufficiently great, this may endanger the safety both of 
the mother and of the child. The dangers to the mother are twofold : 
there is a possibility of the uterus rupturing itself by its efforts; and, 
when the head comes down upon the perineum, if the soft parts be 
rigid there is a very strong probability that they will be lacerated. 
The danger of uterine rupture is, I think, a remote one; for although 
several alleged cases have been recorded, yet in very few is the accident 
clearly traceable to the asserted cause (see Stille, Therapeutics , 2d ed., 
vol. ii. p. 591). The fatal character of the accident is such, however, 
that the possibility of its occurrence should always prevent the reckless 
use of the drug. 

The improper use of ergot is far more serious in its effects upon the 
child than upon the mother. During a violent uterine contraction, the 
passage of the blood from the placenta to the child must be interfered 
with, or, in other words, the respiration of the foetus is temporarily 
stopped, so that its life depends upon the aeration of the blood during 
the intervals. If the latter be very much shortened, the life of the 
child is greatly imperilled; and if they be abolished, it must be de¬ 
stroyed, unless delivery occurs in a very few moments. These consider¬ 
ations are, I think, sufficient, without further discussion, to show the 
imperativeness of the rule never to give ergot in uterine inertia when 
there is much resistance, either in the bony or in the soft parts of the 
mother. In primiparse such resistance is always to be looked for, and 
its degree often difficult to judge of beforehand; and in such women 
ergot should not be used at all for the purposes of expulsion. Even 
under the most favorable circumstances for its employment—when the 
woman has previously borne children, when the bony pelvis is capa¬ 
cious, and the soft parts are relaxed and dilatable—its use should be 
entered upon with caution; and if the accoucheur be skilful in the ap¬ 
plication of instruments, cases must be rare in which the latter are not 
preferable to the ecbolic. 

In women of lax fibre, with roomy pelves, ergot may be used in 
uterine inertia if instruments are not at hand, or if they are objected 
to, or if the obstetrician is timid in their application. 

At the close of parturition, ergot is very commonly employed to 
prevent post-partum hemorrhage; and in this case there is no objection 
to its use, and the remedy is invaluable. But, as it requires from fifteen 
to twenty minutes for its action when given by the mouth, ergot ex¬ 
hibited in this way cannot be relied upon to arrest flooding when it has 


794 


LOCAL REMEDIES. 


already set in. To prevent the occurrence of the latter, it is an excel¬ 
lent rule to give a full dose of the ecbolic when the child’s head is well 
down upon the perineum and beginning to emerge at the vulva. After 
labor, if a tendency to bleeding is manifested, ergot may be administered 
hypodermically. 

For the induction of 'premature labor, ergot has been and still is to 
some extent used; but it is uncertain in its action, and offers no advan¬ 
tages over instrumental methods. 

The success of ergot in arresting hemorrhage after labor soon led 
to its use in uterine hemorrhages in other than parturient or pregnant 
women; and the next step beyond this was its employment in other 
hemorrhages. In all forms of hemorrhage in which no direct local ap¬ 
plication can be made, ergot is to-day probably the most generally used 
remedy; and even when local applications can be made, ergot may often 
be exhibited internally as an adjuvant to the local styptic. It is thus 
employed in menorrhagia , in hcemoptysis, hemorrhage from the gums, 
epistaxis, etc. Ergot acts with especial rapidity and efficiency in these 
cases, if given hypodermically: used in this way, the suddenness of the 
result in haemoptysis is sometimes surprising. Even when the hemor¬ 
rhage is apparently dependent upon a dyscrasia, as in purpura hcemor- 
rhagica, the hypodermic injection of ergotin may produce the happiest 
results (cases, Brit. Med. Journ., ii., 1874; Phila. Med. Times , vol. v.). 
The value of the drug in hemorrhage is no doubt dependent upon its 
power of contracting the small vessels. In colliquative night-sweats 
due to relaxation of the blood-vessels, ergot is a most efficient remedy. 

Allied to its use in hemorrhage is the employment of ergot in en¬ 
largement of the spleen from various causes. Dr. Da Costa was the first 
to suggest hypodermic injections of the drug for this purpose, and he 
claims to have even cured leukaemia (Amer. Journ. Med. Set, Jan. 1875). 

It was the supposed action of ergot upon the muscular fibi’es in 
the walls of the vessels that led Professor Langenbeek to try the effect 
of the hypodermic injection of the remedy in aneurism. The result 
obtained, as reported in the Berlin. Klin. Wochensehr. (vi., 1869), was 
surprising. How far surgeons have followed up this matter I do not 
know ; but, according to Dr. Paul Yogt ( Berlin. Klin. Wochensehr., 
March, 1872), Schneider has cured a case of femoral aneurism, and 
Dutoit one of the subclavian. Yogt has himself employed the remedy 
successfully in a very severe case of varicose veins of the legs, of many 
years’ standing. The remedy is injected into the immediate neighbor¬ 
hood of the aneurism or varix, one or two grains of the extract of 
ergot being employed every day. A good deal of local swelling and 
hardness is induced, and the good achieved has probably been simply 
the result of the local inflammation. 

Yery many years ago, Dr. F. E. Barlan-Fontayral proposed (Journ. 
des Sci. med.-pratiques de Montpellier, tomes vi., vii.) the use of ergot in 
chronic dysentery and diarrhoea, on account of its power of causing con- 


OXVTOCICS. 


795 


traction of the capillaries; and Massolaz, in an epidemic of chronic 
diarrhoea among the French troops serving in the East, found that 
the suggestion was well timed. Although Barlan-Fontayral afterwards 
published a book ( Le Seigle ergote et de VApplication de VErgotine a la 
Care de la Dysenterie et de la Diarrhee chroniques, Montpellier, 1858) 
upon the subject, it attracted little or no attention. In 1871, Pro¬ 
fessor A. Luton, of Kheims ( G-az. Hebdomad ., Oct.), stated, as some¬ 
thing new, that he had used ergot with remarkable success in a violent 
and protracted epidemic of dysentery. Successful cases of chronic diar¬ 
rhoea are also reported by other observers (see Schmidt's Jahrbucher , 
Dec. 1871; Lancet , 1876, ii. 409): so that trials of the remedy should 
be made in all obstinate cases. 

Another employment of ergot for the purpose of restraining exces¬ 
sive secretion is in galactorrhoea , in which affection it has been used 
with success by Dr. Le G-endre (Bull. Therap., t. lxxvii. p. 282), who 
was led to employ it by an observation of Drs. Poyet and Commar- 
mond (Annal. de la Soc. de Med. de Saint-Etienne et de la Loire , 1863) 
that wet-nurses fed upon ergotized bread lost their milk. 

The action of ergot upon the blood-vessels suggests its employ¬ 
ment in those cases in which there is local or general dilatation of the 
vessels. I have used it in pulmonic congestion with apparent good 
results, and it has been highly lauded in the first stages of pneumonia 
by several clinicians, especially by Dr. J. E. Kelly (Med. Register , 
1887), as giving immediate relief when injected hypodermically in low 
forms of pulmonary hypercemia, such as occur in typhoid fevers. It 
will probably also be found of service as a vaso-motor stimulant in 
surgical shock , and it has been used with asserted good results against 
cerebral congestion following injuries to the head. In case of apoplexy , 
by increasing the blood-pressure, its tendency is to do harm rather than 
good. It has also been especially commended in congestion of the spinal 
cord by Brown-Sequard, Hammond, Beard, and others, and I have my¬ 
self used it with satisfaction. Dr. Hampel ( Practitioner , vol. i. p. 263) 
recommends it in whooping-cough. Mr. Woakes believes the pain of 
neuralgia (Ibid., p. 257) to be due to congestion and serous effusion into 
the nerve-sheaths, and has used ergot with asserted good results. Dr. 
Daniel H. Kitchen (Amer. Journ. of Insan., July, 1873) has employed it 
with great success in headaches of the most diverse and even opposite 
origins, and has cured (?) epilepsy with it. In the latter disease he con¬ 
tinues its use for months. Dr. Dehenne (Munich Med., xlv. 86) states 
that he has obtained most remarkable effects in the relief of diabetes 
by subcutaneous injections of ergotin. . The action in the relief of the 
glycosuria, thirst, and polyuria is usually immediate, but in most cases 
the symptoms return upon the cessation of the treatment, although in 
one instance the effect was pei*manent. 

In 1872 (Berlin. Klin. Wochenschr., June 17), Professor Hildebrandt 
announced that in nine cases of fibroid tumors of the uterus he had used 


796 


LOCAL REMEDIES. 


with the utmost advantage hypodermic injections of ergotin; and this 
practice has been followed very widely on this continent. It is scarcely 
to be doubted that cures are sometimes effected; but probably in the 
majority of cases* the drug simply lessens the uterine congestion, and 
does good precisely as it does in chronic subacute metritis and in subinvo¬ 
lution and hypertrophy of the uterus (Meadows, Practitioner , vol. i. p. 
166); it may be that sometimes it strangles the growth by causing 
uterine contractions. If the latter be the case, a cure, as is suggested 
by Professor Goodell (Proceed. Med. Soc. of Pennsylvania , 1873), is to 
be expected from the remedy only in mural and submucoid tumors. 

An objection to the method of Hildebrandt is the great pain and 
local inflammation which often result; and Goodell proposes as a sub¬ 
stitute the use of enemata or suppositories containing the drug. 

Some years ago, led by a fancied resemblance between the physio¬ 
logical action of ergot and that of quinine, Dr. Duboue proposed the 
fungus as a succedaneum to the alkaloid in malarial fevers , and in 
support of his views he published a book entitled Pecherches sur les 
Proprietes therapeutiques du Seigle ergote , Paris, 1873. He brought 
forward some evidence of the value of the remedy; but the latter 
has shared the fate of the older substitutes for the South American 
specific. Dr. Th. Clemens ( Deutsche Klinik, 1865, p. 267) affirms that 
ergot affords the most potent relief in the ammoniacal cystorrhcea of 
paraplegics. He gives it internally, but especially uses injections into 
the bladder of a solution of ergotin (gr. ii to f^v). Ergotin supposi¬ 
tories are asserted to be of great value in hemorrhoids (N. Y. Med. 
Record , xvi. 563). I have used them in one or two cases without 
benefit. 

Toxicology. —Enough has already been said in regard to the acute 
poisoning by ergot, except it be to state that, when abortion is threat¬ 
ened from its ingestion, in the maintenance of perfect quiet and in the 
free exhibition of opium are to be found all the measures of relief at 
our command. 

Since the days of Galen, there have swept over larger or smaller 
districts of Europe epidemics of diseases which have been attributed to 
ergot. In many parts of Europe rye bread forms the great staple 
article of food of the lower classes. It always contains a small quan¬ 
tity of ergot, but not enough to have any deleterious effect upon the 
health. When the summer is wet and cold, the rye becomes very ex¬ 
tensively ergotized, so that the fungus constitutes a large proportion 
of the materials entering into the bread. It is under these circum¬ 
stances that there occur those epidemics of ergotism or chronic ergotie 
poisoning which have been recorded from time to time since the days 
of Galen and of Ciesar. It is not always the rye that causes these 

* See Amer. Journ. Med. Sci., July, 1873; Amer. Practitioner, May, 1873, May, 1874, 
August, 1874; Clinic, April, 1873 ; Lancet, May, 1873; Chicago Med. Journ., 1874; and es¬ 
pecially Dr. Byford’s Address, Trans. Amer. Med. Assoc., 1875. 



OXYTOCICS. 


797 


frightful losses of life, as Heusinger (Journ. fur Pharmakodyn ., Bd. i. p. 
405) has traced one epidemic to diseased oats. Before going further, 
it seems proper to state that Trousseau and Pidoux assert that these 
epidemics are not dependent upon any specific action of ergot, but 
are either epidemics of blood-diseases or simply the results of im¬ 
proper and insufficient food,—the outcomes of poverty, wretchedness, 
and famine. It seems to me indisputable that some of the various 
epidemics which have been recorded were of this character, but cer¬ 
tainly it is no less indisputable that others were not. Moreover, 
numerous scattered cases are on record in which a few persons or a 
family have been affected with ergotism unmistakably traceable to tbe 
use of bread largely composed of the fungus.* 

The scojDe of the present work is such as to forbid my entering into 
an elaborate discussion of the epidemics of ergotism, especially as the 
subject has no practical bearing so far as the American profession is 
concerned, since the absence of deep poverty is so complete in our 
country that no one would feed on largely ergotized bread; and, in fact, 
no case of ergotism has as yet been recorded as occurring in the United 
States.f 

There are two varieties of ergotism,—the spasmodic and the gan¬ 
grenous. 

Gangrenous ergotism has been especially observed in Prance, and is 
believed to be the same as the Ignis Sacer or the Ignis Sancti Antonii 
of the Middle Ages,—an affection which in 922 killed forty thousand 
persons in Southwestern France, and in 1128-29 fourteen thousand in 
Paris alone. It generally commences with itching and formications in 
the feet, severe pain in the back, contractions in the muscles, nausea, 
giddiness, apathy, with abortion in pregnant women, in suckling women 
drying of the milk, and in maidens amenorrhoea. After some time, 
deep, heavy, aching pains in the limbs, an intense feeling of coldness, 
with real coldness of the surface, profound apathy, and a sense of utter 
weariness, develop themselves. Then a dark-red spot appears on the 
nose or on one of the extremities; all sensation is lost in the affected 
part; the skin, perhaps over a large surface, assumes a livid red hue, 
and in the foci of local changes bullae filled with serum appear. The 
adynamic symptoms, in severe cases, deepen as the gangrene spreads, 
until finally death puts an end to the scene. Very generally the ap¬ 
petite and digestion are preserved to the last, and not rarely there is 
an almost ferocious hunger. The gangrene is generally dry, the parts 
withering and mummifying; but sometimes it is moist, and pyaemic 
symptoms may even be developed. Of course a very large number of 


* For an account of a modern epidemic, see Deutsch. Arch. f. Klin. Med., xxxiii. 246. 
f Any one especially interested in the subject will find the literature very well repre¬ 
sented in the references of Professor Stillfi’s work on Therapeutics, to which may be added 
Duboul’s book, quoted on the previous page. For the reader of German, a very excellent 
resume exists in Husemann’s Handbuch der Toxicologie. 



798 


LOCAL REMEDIES. 


cases do not terminate in death; but the part immediately affected is 
generally lost. In these cases the toes most generally are the portion 
destroyed, but it may be any one or all of the extremities; and the 
nose, lips, ears, and even the buttocks, sometimes bear the brunt of the 
disorder. 

Spasmodic ergotism may in the lightest cases be manifested only by 
itching, formications, numbness, or complete anaesthesia of the fingers 
and toes or of the buttocks, and by gastro-intestinal irritation, as shown 
by colic, vomiting, diarrhoea, or constipation, and withal a ravenous 
hunger. In more severe cases these manifestations are intensified, and 
spasmodic symptoms appear, violent and painful tonic contractions 
affecting especially the flexors of the extremities, interrupted at times 
by intervals of quiet, but gradually growing into severe general tetanic 
paroxysms, with opisthotonos and emprosthotonos. In the intervals 
there are very generally muscular tremblings, and as the case progresses 
there are developed cerebral manifestations, such as disturbances of 
vision, photophobia, chromopsia, hemiopia, and periodic amblyopia and 
amaurosis, giddiness, cataleptic and epileptic paroxysms with or with¬ 
out loss of consciousness, delirium, and idiocy. Gastro-intestinal symp¬ 
toms are always very marked, but with them is a characteristic ravenous 
hunger and a longing for sour food and drink. The skin is earthy or 
yellowish in its tint, and is often spotted with boils or pustules or semi- 
gangrenous vesicles. Death is apparently caused by exhaustion; and in 
those that recover, various local paralyses, habitual spasms, amaurosis, 
mental aberrations, or even idiocy, often remain through life. In a 
few cases the symptoms are still more violent, and the spinal and 
cerebral disturbances soon lead to death. 

In some epidemics of ergotism the cases have been a mixture of the 
spasmodic and gangrenous forms of the disease. 

Administration. —Ergot may be given in powder, but at present 
this method is very rarely used: the dose is half a drachm to two 
drachms. The U.S. Pharmacopoeia recognizes a wine (Vinum Ergotce, 
—1 to 6.6) and a fluid extract (Extractum Ergotce Fluidum ). The first 
of these is a good preparation for internal use, and may be adminis¬ 
tered, as an ecbolic, in doses of half an ounce to two ounces. The fluid 
extract is, however, preferable. The usual ecbolic dose is one to two 
drachms. In nervous diseases much larger doses are required: thus, 
in congestion of the spinal cord I usually begin with half an ounce, 
and increase it to an ounce three times a day.* Of the so-called Ergotin 
two varieties have been proposed, that of Bonjean and that of Wiggers. 
Bonjean’s ergotin is made by exhausting the ergot with water, evapo- 


* It would appear that sometimes, owing to idiosyncrasies, even small amounts of ergot 
cause much disturbance. Thus, Dr. R. B. Faulkner reports (Neio York Med. Journ., June 
14, 1884) a case in which a fluidrachm of the fluid extract caused great sleepiness, swelling 
and redness of the feet, and violent prickling of the extremities, probably as the outcome of 
gastric irritation. 



OXYTOCICS. 


799 ‘ 


rating to the consistency of a syrup, precipitating the albumen, gum, 
etc., with an excess of alcohol, decanting the clear liquid, and evapo¬ 
rating to the consistency of a soft extract. This ergotin is believed to 
be about ten or eleven times as strong as ergot, five or six grains of it 
representing about a drachm of the drug. 

The ergotin of Wiggers simply contains everything in the ergot 
which is insoluble in water. Kohler ( Virchow's Ai’chiv, Bd. lx.) has 
proved that Wiggers’s preparation has no influence upon the circula¬ 
tion, but in toxic doses produces violent convulsions. It ought not to 
be employed therapeutically. Bonjean’s ergotin is that usually kept 
in our pharmacies, and represents all the virtues of the remedy. The 
officinal extract of ergot (Extraction Ergotce , U.S.) is as good for hypo¬ 
dermic use as Bonjean’s ergotin, and in all respects represents the 
drug therapeutically. Its strength is five times that of the fluid ex¬ 
tract ; when used hypodermically five grains should be dissolved in five 
minims of glycerin, ten minims of boiled water, and half a minim of 
carbolic acid, and filtered: the danger of severe local trouble is also 
lessened by plunging the nozzle of the syringe deeply into the mus¬ 
cular tissues. 

Gossypii Radicis Cortex, U.S.—The root of the ordinary cotton- 
plant is asserted to be used by the negroes in various portions of the 
South as an abortifacient , and Ur. Bouchelle, as long ago as 1841, claimed 
for it medical properties similar to those of ergot. It has not, however, 
come into general use, and our knowledge of its properties is at present 
very scanty and uncertain. In the experiments of Ur. I. C. Martin 
enormous doses produced heaviness and stupor in both frogs and mam¬ 
mals, but did not cause abortion in pregnant guinea-pigs and rabbits: 
neither the spinal cord, the muscles, nor the nerves were affected (Amer. 
Journ. Med. Sci., Jan. 1882); but Ur. H. I. Garrigues has found it a 
most serviceable agent in arresting hemorrhage and ameliorating the 
other symptoms in uterine polypoid and fibroid tumors, and even in 
uterine cancer. He insists that the commercial fluid extract is inert 
and the decoction must be freshly prepared ( Quart. Bull. Clin. Soc., New 
York, Jan. 1887). The oxytocic dose of a decoction (giv in a quart of 
water boiled to a pint) is stated to be a wineglassful, to be repeated 
every thirty minutes as necessary. The remedy has also been employed 
in amenorrhcea and in dysmenorrhcea , in which diseases from three to 
five grains of a solid aqueous extract have been given three times a 
day. The fluid extract (Extraction Gossypii Radicis Fluidum , U.S.) may 
be used in doses of a fluidrachm. 

The Smut of Indian Corn (Ustilago , U.S.) appears to have active 
medicinal properties, and should be investigated. It has been used with 
alleged success in uterine inertia during labor by Uujardin-Beaumetz 
(Bull. Therap ., xciii. 85). Ur. James Mitchell has found that in the 


800 


LOCAL REMEDIES. 


frog the ustilago maidis abolishes sensation and reflex action before 
voluntary motion; he states that reflex action is destroyed at a time 
when motor nerves and muscles are still active, and that consequently 
the first influence of the poison is upon the sensoiy side of the lower 
nervous system; late in the poisoning the whole motor tract became 
involved ( Therap. Gaz ., ii. 223). It has been employed in the Phila¬ 
delphia Hospital during labor by Dr. W. A. H. Dorland, who has found 
that in doses of one to two drachms of the fluid extract it has a very 
marked influence upon the uterine pains, increasing them in severity, 
frequency, and duration. He claims for it that it will not produce a 
prolonged tonic contraction as does ergot. This is, however, doubtful. 
(Consult also N. Y. Med. Journ ., xxiv. 654; Schmidt's Jahrbucher, Bd. 
clxxii. p. 19; Centralbl. fur Med. Wissench., 1876, p. 228; Chicago Med. 
Times, 1879-80, xi. 434). 


FAMILY IX.-SIALAGOGUES. 


Sialagogues are medicines which increase the flow of saliva and of 
the buccal mucus. Yarious substances, such as mercury, when taken 
internally, affect the mouth and its tributary glands in such a way as 
to produce salivation : these substances are, however, never employed 
in medicine for this purpose, so that practically sialagogues are local 
remedies acting by the induction of a local impression on the mouth. 
The influence which they exert is a stimulant one, and most of them 
are more or less irritant. They are used to effect two distinct purposes. 
Some of them dissolved in the saliva pass over and directly stimulate 
the mucous membranes not only of the mouth but also of the fauces 
and of the epiglottis. Other sialagogues, by exciting a very great flow 
of saliva, seem to lessen the congestion of the part. 

In reference to the first of these modes of action, sialagogues are 
employed in relaxed conditions of the mucous membrane of the fauces, 
and even of the larynx. Chief among the substances so used is cubebs, 
which when slowly chewed in the mouth exerts a very decided local in¬ 
fluence, and is useful in relaxation of the fauces, of the uvula, and even 
of the upper portions of the larynx. Either in the form of the berries 
or made into lozenges, cubebs is much used by public speakers; and 
in the hoarseness from relaxation following over-use or slight inflamma¬ 
tion, it is often very efficient. Through their depletory influence, siala¬ 
gogues are sometimes useful in allaying rheumatic toothache , or other 
rheumatic irritations about the jaws. 

Pyrethrum, or Pellitory, is the product of Anacyclus Pyrethrum, a 
small herbaceous perennial, growing in the neighborhood of the Medi¬ 
terranean. It is a small root, about the size of the little finger, wrinkled 
longitudinally, light brown externally, with bright, shining spots on the 
surface, hard, brittle, with aresinoid radiated fracture. It is inodorous, 
and when chewed is at first almost tasteless, but soon becomes acidulous, 
saline, and acrid, and produces a very persistent burning, tingling sen¬ 
sation, which is accompanied by a profuse flow of saliva. Half a drachm 
to one drachm of it may be chewed at a time in painful rheumatic affec¬ 
tions of the face , in toothache , in relaxation of the uvula , and in similar 
disorders. Taken internally in excess, it acts as a narcotic irritant, 
fifty minims of its tincture having caused gastro-intestinal irritation, 
with violent convulsions, which nearly proved fatal, in a child three 
and a half years old ( Practitioner , xvii. 86). 

51 


801 



FAMILY X.-ERRHIXES. 


These are substances employed to act upon the mucous membrane 
of the nose. Strictly speaking, the term should be applied only to those 
drugs which are used to excite secretion in the nasal mucous mem¬ 
brane. Such remedies are, however, so rarely used as to be by them¬ 
selves scarcely worthy of notice. The employment of irritating vapors 
to arouse the nerve-centres by stimulating the nerves distributed in 
the nasal mucous membrane is a very old and a very popular custom. 
Smelling-salts , or preparations of hartshorn, so much used by ladies as 
a slight stimulant, and by others in reviving those who are suffering 
from or threatened with fainting, act in this manner. The ammonia 
held close to the nostrils brings about the reaction, not by any direct 
stimulating action on the circulation, but by irritating the nasal mucous 
membrane, as is proved by the rapidity of its influence and by the ex¬ 
ceedingly minute quantity which will sometimes act efficiently. In the 
use of hartshorn, especially with young children, it is necessary to exer¬ 
cise care, lest injury be done to the delicate mucous membrane. The 
only errhine used for the purpose of influencing affections of the nasal 
passages themselves which is worthy of mention here is cubebs. This 
freely snuffed up in powder is very useful in acute coryza, after the first 
stage of congestion and dryness has passed away. 


802 



FAMILY XI-EPISPASTICS. 


Counter-irritation .—Almost from time immemorial, physicians have 
believed that morbid processes in deep-seated or superficial organs 
could be modified by irritations artificially induced in distant parts. To 
the drugs used for producing these remedial irritations the name of 
revulsives, or counter-irritants, has been given, the process being called 
revulsion, or counter-irritation. Latterly, the value of these remedies 
in disease has been questioned, chiefly because not only were the ac¬ 
cepted theories of their action deemed untrue, but also any explanation 
of how they do what is claimed for them was asserted to be, in the 
present state of our knowledge, inconceivable. 

Evidently, in studying the matter, the inquiry should be divided into 
two parts, and fact should be separated from theory; the effort being 
made to ascertain, first, whether experience does or does not demon¬ 
strate that it is possible by an irritation to affect a distant part which 
has no apparent connection with the seat of the new irritation; secondly, 
whether the facts taught by experience are in truth irreconcilable with 
reason. In regard to the first part of this inquiry, it seems to me in¬ 
disputable that experience does teach, in the most unequivocal manner, 
that an organ may be affected through a distant part. There are 
physiological proofs of this, which it is only necessary to allude to: 
such is the relation of the uterus and the mammary glands. The proofs 
which may be drawn from disease are, however, much more numerous 
and striking. Thus, it is well known that in mumps there may be 
relief of an existing irritation of the salivary gland by a new irritation 
of the testes; in gout, the swelling of the toe will relieve the dis¬ 
ordered digestion, etc. If it be affirmed that these phenomena, happen¬ 
ing during the existence of a blood-disease, are sui generis , the objection 
cannot be made to the paraplegia produced by the irritation of a calcu¬ 
lus in the kidney, or to the headache due to the irritation of the gastric 
mucous membrane by acid, or to the shoulder-pain of diseased liver, or 
to the amaurosis caused by the irritation of a decayed tooth. A well- 
known experiment of Brown-Sequard’s illustrates the point so well that 
it may be quoted. In it he found that if one sciatic nerve of a guinea- 
pig be cut, epileptic attacks may be produced by gently rubbing the 
back of the ear upon the same side. A very curious instance of an 
external irritation affecting a deep-seated part is the duodenal ulcer 
produced by burns, especially of the abdomen. The pathological evi- 



804 


LOCAL REMEDIES. 


dence of the truth of the present proposition is simply overwhelming, 
and facts might be brought forward almost indefinitely to show that 
irritations are capable of affecting the functions and nutrition of distant 
parts. This being true, surely it is in the highest degree reasonable to 
suppose that artificial irritations can in a greater or less measure be 
controlled so as to affect the distant organ for good and not for evil. 

Clinical experience has certainly demonstrated that this can be done. 
The value of any individual counter-irritant in this or that disease is 
not the present question; but certainly no physician who has had any 
practice can have failed to see instances of relief from the use of 
counter-irritants. A case of obscure brain-trouble recalls itself at pres¬ 
ent writing, in which stupor and a clear intellect alternated at will, 
according as the drastic cathartic was given or withheld. The relief 
of abdominal pain, or “ stomach-ache,” by a mustard plaster, is a daily 
nursery experience. 

From what has been already stated, it may be laid down as proved 
beyond cavil—first, that we have power to influence internal morbid 
processes by creating external irritations; secondly, that the fact of 
counter-irritation exists, whether we can or cannot explain its rationale. 

Physiological knowledge is not yet sufficiently extensive to enable 
us to perfect a theory of counter-irritation. The action of these reme¬ 
dies is complex, but I think can be explained at least in part. There is 
only a certain amount of blood in the body. If it be accumulated in 
one place, it cannot be in another. Thus, the difficulty of studying 
after a hearty dinner probably depends, as do the cold feet so common 
in feeble persons under such circumstances, upon the accumulation of 
blood, and probably also of nervous energy, in the digestive organs. 
Now, by artificial interference, by determined study, by violent exer¬ 
cise, we can often draw the blood away from the alimentary apparatus 
into the cerebrum, or into the motor system, and produce indigestion. 
Clinical experience proves that we can also reverse this process. The 
brain is excited, the blood is concentrated in it, congestion exists, in¬ 
flammation is threatened; a drastic cathartic is given, the blood is 
drawn into the intestinal canal, and by revulsion the brain is relieved. 
Certainly this is not mysterious, not inexplicable. All forms of counter- 
irritation cannot, however, be explained on the above principle. It is 
a probable, but not a positive, teaching of modern physiology that 
there are nerves which preside over nutrition,—the so-called trophic 
nerves. If this be so, it is to be expected, a priori , that peripheral irri¬ 
tations will cause reflex alterations of nutrition, precisely as they cause 
reflex disturbances of the motor functions. Further, whether these 
trophic nerves do or do not exist, there are vaso-motor nerves, and the 
duodenal ulcer of burns is a positive proof that, either through the 
trophic or through the vaso-motor nerves, external irritations do pro¬ 
duce internal reflex alterations of nutrition. The sympathetic ophthal¬ 
mia caused by a morbid eye in its healthy fellow, or induced by a 


EPISPASTICS. 


805 


diseased tooth, is another instance of this reflex alteration of nutrition. 
As this is true, it seems to me absurd to state that it is impossible to 
conceive how an external counter-irritant can affect the nutrition of a 
deep-seated organ. 

It is evident that in all the cases which have been mentioned of 
external irritation causing disease in a distant organ there is no direct 
communication between the part irritated and the organ which is 
secondarily affected. And clinical experience confirms the evident de¬ 
duction from this,— i.e ., that it is impossible to determine, except by 
experiment, where the counter-irritant should be placed to affect most 
powerfully any given organ. It has, however, been clinically demon¬ 
strated that the general law for deep-seated parts is that the revulsant 
should be put directly over the part. When a superficial action is de¬ 
sired, other directions are needed. We are indebted to Dr. Anstie for 
pointing out what appears to be another law,—namely, that when a 
superficial part supplied by the anterior branches of a spinal nerve is 
to be affected, the counter-irritant should be placed over the posterior 
roots of the nerve. Not only can obstinate neuralgia often be relieved 
by this reflex action, but also the inflammatory changes so often coinci¬ 
dent with intercostal neuralgia. The law seems also to apply to cervi¬ 
cal nerves, since the proper position for the blister in facial trigeminal 
neuralgia is back of the ear or on the nape of the neck. Dr. A. Du- 
montpallier affirms that the best results of counter-irritation are ob¬ 
tained by applying the counter-irritant upon the opposite side of the 
body, so as to be exactly symmetrical with the pain, and especially 
commends hypodermic injection of water as a counter-irritant (Gaz. 
Hebdo?nadaire, Nov. 14, 1879). 

Counter-irritants may be conveniently arranged under two heads: 
first, those which produce a decided structural alteration of the skin, 
including epispastics; second, those which do not provoke decided alter¬ 
ations of dermal structure, the rubefacients. The indications for the use 
of these substances can best be considered under their respective head¬ 
ings- 

As is well known, any sthenic inflammation, if of sufficient extent 
and intensity, may excite the general system even to the point of high 
fever. In this respect inflammation of the skin does not differ from 
that of other organs. Hence dermal irritants have a direct tendency 
to arouse or excite the system, and may be used as general stimulants. 
It will be seen at once that it is the nervous and arterial systems which 
alone feel their influence. Hence the irritants should not be relied upon 
in cases of exhaustion, for the only possible source of absolute increase 
of power to the system is in food; and in exhaustion those stimulants 
should be employed which increase the power of assimilating food. 
For this reason, external irritants are useful as stimulants in conditions 
of depression rather than of exhaustion. Such conditions of depression 
exist in acute collapse from any cause, in “ shock" following injuries, in 


806 


LOCAL REMEDIES. 


the first stage of pernicious malarial fever , in snake-bite , and in other 
cases when the powers of the system are seemingly overwhelmed by 
some depressing agency. The rubefacients are preferable to blisters 
for this purpose, because their local after-effects are comparatively so 
trifling that they can without injury be applied to a very large extent 
of the surface. 

Epispastics, vesicatories, or, more colloquially, blisters, are substances 
which are used by the physician to produce that peculiar inflammation 
of the cuticle and outpouring of serum known as a blister. The im¬ 
mediate effect of a blister is more severe and more permanent than 
that of a rubefacient. Blisters are especially useful in inflammations 
of serous membranes, such as pleuritis and peritonitis ; are very strongly 
recommended by some practitioners in parenchymatous inflammations, 
such as pneumonia ; and are often of service in neuralgia , and in other 
forms of nervous irritation, such as the maniacal delirium of fevers, 
when dependent upon the irritant action of a blood-poison, and not 
upon exhaustion. The amount of serum which is poured out from a 
blister is sometimes quite large, and vesicants have even been used to 
relieve dropsy. In general dropsy their use is simply unjustifiable; but 
in local dropsies , as, for example, serous effusion into the pleural sac or 
into the pericardium, dependent upon local disease, they often do good, 
not only by affecting favorably the disease-process, but also by hasten¬ 
ing the removal of the effusion. 

In some chronic affections, long-continued severe counter-irritation 
is required: in such cases a blister may be “ kept open” by the use of 
stimulating ointments, such as the unguentum mezerei. In chronic in¬ 
flammation of the joints, repeated blistering is very often of service. 
When the inflammatory action is rheumatic, in my experience better 
results are obtained by repeated blistering than by keeping a blister 
sore by means of irritants. In neuritis, whether rheumatic or other¬ 
wise, blisters are often of service: they should be applied as a long 
narrow strip along the course of the nerve. In obstinate local neural¬ 
gia, very mild blistering over the seat of pain, or in accordance with 
Anstie’s law, is sometimes advantageous. 

The contra-indications to the use of blisters are high arterial and 
febrile excitement and a decided want of vital power. In the former 
case, the irritating influence which they exert upon the general system 
may increase the constitutional disturbance to such an extent as to do 
far more injury than any local benefit derived from them can do good. 
When the vitality is very weak, blisters may give rise to sloughing 
ulcers, which, refusing to heal, may waste very seriously the already- 
exhausted system. Hence, in all acute diseases of such type that the 
nutritive forces are exceedingly depressed, blisters must be avoided, or 
must only be used with great caution. For the same reason, great care 
must be exercised in their employment in the very young or the very 
aged. Yery rarely indeed is a blister called for in the case of a young 


EPISPASTICS. 


807 


infant, and, when employed, it should be allowed to remain in contact 
with the skin only just long enough to produce slight redness, and the 
complete vesication should be obtained by the use of the poultice. 

There are various substances which are capable of producing vesi¬ 
cation, but the only one in ordinary use is cantharides. In cases of 
emergency, a blister, it is said, may be raised in a very few minutes 
by the use of the stronger water of ammonia , a little of which is to be 
kept in contact with the skin by means of an inverted watch-glass. It 
is necessary to watch the process closely, and to remove the irritant as 
soon as vesication has occurred, as the ammonia is very capable of 
causing sloughing. 

CANTHARIS—CANTHARIDES. U.S. 

The dried bodies of the Cantharis vesicatoria, a beetle inhabiting 
Southern Europe, and coming into commerce in Spain, Italy, Sicily, 
and the southern provinces of Russia. Spanish flies are from half an 
inch to nearly an inch in length, and two to three lines in breadth, and 
have a large heart-shaped head, and brilliant metallic-green elytra, or 
wing-cases. Their odor during life is very strong and fetid, but is 
almost entirely lost in drying; their taste is urinous, very burning, and 
acrid. They are taken in May and June, when they swarm on the 
trees which they affect, by beating the branches early in the morning, 
when the insects are torpid from the cold, catching them upon linen 
sheets, and plunging them into hot vinegar-and-water, or exposing 
them to the fumes of boiling vinegar. In some places they are gath¬ 
ered by smoking the trees with the fumes of burning brimstone. 
When ground, Spanish flies afford a grayish-brown powder, full of 
minute greenish spangles, the remains of the feet, head, and wing-cases. 
The active principle of cantharides is Cantharidin, which occurs in 
white crystalline scales, is inodorous, tasteless, insoluble in water, nearly 
so in cold alcohol; soluble in ether, benzole, the oils, and very freely so 
in chloroform. Notwithstanding the insolubility of pure cantharidin, 
Spanish flies yield their virtues to alcohol and to water. 

Physiological Action.— When a minute therapeutic dose of can¬ 
tharides is taken, no perceptible immediate result is produced, and after 
a somewhat larger quantity the only symptom is usually some burning 
and pain in urination. Doses more than just sufficient to induce this 
should not be employed in medicine, as the symptoms produced by 
large amounts of the drug are exceedingly severe and distressing. 
Cantharides is very irritating, and, when applied to the skin, causes at 
first redness, with burning, then free vesication and severe pain, and, 
if the contact be longer maintained, deep inflammation and sloughing. 
XJpon the mucous membranes it produces a no less intense effect; and 
consequently gastro-intestinal inflammation forms a prominent symptom 
of poisoning by it. Further, the active principle or principles are un¬ 
doubtedly absorbed and are eliminated by the kidneys, coming in con- 


808 


LOCAL REMEDIES. 


tact with almost the whole genito-urinaiy mucous membrane: hence 
intense irritation and inflammation of these organs always result from 
the ingestion of an overdose of Spanish flies. 

Very soon after a toxic dose of cantharides has been taken, the 
sufferer is seized with burning in the pharynx and oesophagus, and a 
sense of stricture in the throat. The pain soon spreads to the stomach, 
and vomiting comes on. The symptoms rapidly increase in severity ; 
the abdominal pain becomes very severe, and, in the majority of cases, 
purging takes place. The matters rejected by the stomach are first 
mucous (with, if the drug have been taken in powder, little greenish 
specks through them), then bilious, and finally bloody. The stools are 
mucous, then fibrinous, bloody, becoming often very scanty, but exces¬ 
sively numerous, and in their passage accompanied by great tenesmus. 
Probably in most cases, very early in the attack severe salivation is 
developed, and is frequently accompanied by great swelling of the 
salivary glands. Sometimes death occurs in a very short time, from 
collapse produced by the intense gastro-intestinal inflammation; but 
more generally it is postponed for some hours, and a new train of 
symptoms arises. Aching pains in the back, and very frequent mic¬ 
turition, indicate the commencing urino-genital irritation. These symp¬ 
toms increase in intensity until there is a constant irresistible desire to 
urinate, with violent tenesmus of the bladder, and yet an inability to 
pass more than a few drops of urine, which is albuminous, and not 
rarely bloody. In some cases there is a violent erotic excitement, an 
unquenchable lust, accompanied in man by numerous seminal emis¬ 
sions ; violent priapism, swelling and heat of the organs, and even 
severe inflammation of the parts, indicate the intensity of the local 
action of the poison; sometimes gangrene ultimately occurs. 

Neither amatory desire nor true priapism is, however, a constant 
symptom in cantharidal poisoning (cases, Journ. de Pharm. et de Chimie , 
June, 1871): indeed, the former is probably absent in the majority of 
cases. Consciousness and general power are often long preserved amid 
intensely severe local symptoms and agony, but, if the dose have been 
large enough, sooner or later collapse comes on, with the usual accom¬ 
paniments, and the prostration deepens into complete powerlessness, 
stupor, coma, and finally death. In some cases violent hydrophobic 
delirium and severe tetanic convulsions are said to have occurred 
(Tardieu). Paraplegia has been noticed in several cases by Dr. Palle 
{Journ. de Pharm. et de Chimie , June, 1871): it was probably reflex in 
its origin, and due to the intense irritation of the genito-urinary organs. 

In animals, cantharides produces very much the same symptoms as 
in man. In dogs, according to the experiments of Orfila and of Beau- 
poil, the symptoms of gastro-intestinal inflammation are more promi¬ 
nent than those of irritation of the genito-urinary tract. It has been 
asserted that the lack of erotic excitement in these cases shows that the 
medicine acts dilferently upon man and upon animals. As already stated, 


EPISPAS TICS. 


809 


however, erotic delirium is very generally absent in fatal poisoning in 
man, while Schroff states that ten drops of the tincture of cantharides 
will frequently produce great sexual excitement in man, and the whole 
drift of the evidence is that libidinous desires are much more apt to be 
caused by amounts of Spanish flies but slightly toxic than by fatal 
doses. Indeed, the irritation caused by the latter would seem to be 
too intense, the general perturbation too great, for erotism to be in¬ 
duced. There appears to be some difference in the effects of different 
doses of the drug upon animals. Fatal doses very generally do not 
excite sexual desire; but Schubarth (quoted by Stille) found that 
small doses do cause evident salaciousness and irritation of the genital 
organs, while, according to Husemann (Handbuch der Toxicologie , 1862, 
p. 264), the peasants of Northern Germany habitually give cantharides 
to cows when backwai’d in coming into heat at the proper season. 
According to Dr. Cautieri (Schmidts Jahrb., Bd. clxv. p. 237), toxic 
doses of cantharides rapidly lessen blood-pressure and the force of the 
cardiac pulsations, but markedly increase the pulse-rate. He found 
in animals killed with cantharides marked hypersemia of the brain 
and spinal cord, and nephritis. M. Galippe (Gaz. Hebdom., 1874, p. 439) 
noted inflammation of the alimentary canal, kidneys, and bladder. 

Therapeutics. —Cantharides is employed internally only for the 
purpose of influencing the genito-urinary organs; and sufficient has 
already been said in regard to this use under the headings of Diuretics 
and Emmenagogues. The external use of cantharides is simply as a 
vesicant; and the employment of blisters has been sufficiently consid¬ 
ered in the general discussion of the class. Two points, however, seem 
worthy of notice here: first, that this drug affords the only practical 
means of blistering at our command; secondly, that when it is freely 
employed there is always some danger of the absorption of a sufficient 
amount of the active principle for strangury to be induced. In sus¬ 
ceptible persons, therefore, care has to be exercised in the use of 
epispastics; and whenever active irritation of the kidneys exists, can- 
tharidal blisters should not on any account be applied. 

Toxicology. —Sufficient has already been said about the symptoms 
produced by cantharides. The minimum fatal dose is not certainly 
determined, and probably varies very much. According to Stille, 
twenty-four grains of the powder, taken in two doses, have caused 
fatal abortion, and an ounce of the tincture has destroyed life after 
the lapse of a fortnight. After death, intense injection, swelling, 
patches of exudation, loss of epithelium, and other results of inflam¬ 
mation are found along the whole tract of the alimentary canal; in¬ 
tense hypersemia of the kidneys, with contraction and injection of the 
bladder, also usually exists. According to the experiments of Aufrecht 
(Centralbl. f. Med. Wissen., 1882, xx. 850), all the forms of nephritis 
may be produced by cantharidin, but it is probable that in most cases 
of poisoning the first change is exudation of the white blood-corpuscles, 


810 


LOCAL REMEDIES. 


rapidly followed by a desquamative nephritis, with profound alteration 
in the glomerules (see Dr. Ida Eliaschoff, Virchow's Archiv , xciv. 323). 

There is no known antidote to cantharides, and the treatment of the 
poisoning must be conducted upon general principles. The stomach, 
if not already thoroughly emptied, should be evacuated at once by a 
stimulating emetic if the stomach-pump be not at hand. Large quan¬ 
tities of mucilaginous or albuminous drinks should be taken; and all 
oily substances should be avoided, as favoring the solution, and conse¬ 
quently the absorption, of the poison. Opium should be freely exhib¬ 
ited, especially by the rectum, to allay pain and relieve the strangury. 
For the latter purpose warm sitz-baths or general baths should be given. 
In some cases leeches to the epigastrium are advisable. When the suf¬ 
fering is very intense, the cautious use of anaesthetics seems to me not 
only justifiable, but imperative. In the stage of prostration, the meas¬ 
ures to be adopted are those commonly practised in collapse from poison. 

Administration.— The preparation of cantharides most commonly 
used for the production of a blister is the Cantharides Cerate (Ceratum 
Cantharidis , U.S.), which is best spread upon sticking-plaster in such a 
way as to leave a margin about an inch in width, which shall adhere 
to the skin and hold the plaster in its place. The Cantharides Paper 
(Charta Cantharidis , U.S.) is thought to be more elegant than the 
plasters made of the cerate, and is said to be efficient. In order for a 
blister to “ draw” thoroughly, it usually has to be left on some eight 
hours; but in most cases the same result can be achieved with less 
suffering by allowing the blister to remain only five or six hours, or 
until decided redness and slight vesication have been induced, and then 
applying a flaxseed poultice. In certain localities vesication requires a 
much longer application than that just spoken of: thus, upon the 
shaved scalp a blister will rarely act efficiently in less than twelve 
hours, and often not in that time. In maniacs, in the delirious sick, in 
children, and in other unruly patients, it is often necessary to put on a 
blister in such a way that the sick person has no control over it. For 
this purpose the Cantharidal Collodion (Collodium cum Cantharide , U.S.)* 
may be used. It is ordinary collodion impregnated with cantharides, 
and on evaporation leaves an adhesive blistering film: two or three 
coats of it should be applied, by means of a camel’s-hair brush. When 
there is any especial danger to be feared from absorption of the active 
principle, the use of the poultice, after a brief application of the blister 
as described above, should always be practised. The Liniment of Can¬ 
tharides (Linimentum Cantharidis , U.S.) contains turpentine, and is used 
as a violent rubefacient liniment. The Ceratum Extracti Cantharidis , 
U.S., is probably an efficient blistering preparation, but has not been 
much tested. The tincture (Tinctura Cantharidis, U.S.) is used inter¬ 
nally in doses of three to five drops. 


* For a case of poisoning by cantharidal collodion, see Phila. Med. Timet, iv. 312. 



FAMILY XII—RUBEFACIENTS. 


Rubefacients are those remedies which are employed for the pur¬ 
pose of producing not any permanent inflammation of the skin, but a 
general intense irritation, redness, and congestion, which shall exert a 
temporary influence, whose power is the result of the large surface af¬ 
fected, and not of any permanent impression upon the nutritive acts 
of that surface. Most, if not all, rubefacients are capable of causing 
disorganizing inflammation if allowed to remain for too long a time in 
contact with the skin. 

The superiority of rubefacients over blisters when it is desired to 
arouse or stimulate the system has already been pointed out (see p. 806). 
It remains to speak of the use of rubefacients in local diseases. They 
are especially useful in sudden cases of severe pain due, it may be, to 
acute congestion of a part or to some internal irritation, like that of 
gout. Thus, in the ordinary intestinal pain caused by irritant articles 
of food, or more commonly by a rheumatic, gouty, or other irritation 
following exposure to cold or wet, rubefacients are most useful. In 
this as in all other cases of what may be termed temporary functional 
derangement, when a counter-irritant is desired, rubefacients are supe¬ 
rior to blisters, because their effects are not nearly so lasting, and also 
because, for the time being, they seem to impress more powerfully the 
nervous system, breaking up, as it were, the concentration of nervous 
energy, or calling off the irritation, or impressing the nervous system 
in some way which in our present ignorance it is difficult to find terms 
to express. A correct idea of the difference in the use of the two classes 
of counter-irritants can perhaps be conveyed by saying that when pro¬ 
found local alterations of nutrition are to be dealt with, blisters are to 
be used; when functional disturbance is to be met, rubefacients are 
to be employed. Blisters are useful in inflammations; rubefacients, in 
congestions. Yet this rule cannot be applied with rigidity. 

SINAPIS ALBA—WHITE MUSTARD. U.S. 

SIN APIS NIGRA—BLACK MUSTARD. U.S. 

The seeds of Sinapis alba and Sinapis nigra respectively,—Euro¬ 
pean crucifers, cultivated in the temperate regions of the world. These 
seeds are minute, globular bodies, yellowish within: they are to be dis¬ 
tinguished one from the other by the smaller size, external brown color, 

811 



812 


LOCAL REMEDIES. 


and more fiery taste of the black mustard, and the light-yellowish ex¬ 
terior of the white mustard. 

Black Mustard contains Myronic Acid in combination with potash, 
and also a peculiar albuminous principle, Emulsin. When to these sub¬ 
stances water is added, a reaction occurs, resulting in the production 
of a volatile oil out of the myronic acid. Volatile oil of mustard is a 
colorless or yellowish fluid, of an intensely pungent, or even corrosive, 
odor and taste. A momentary contact with it suffices to redden and 
blister the skin, and mucous membranes are said to be rapidly destroyed 
by its vapors. 

White Mustard does not yield on distillation with water a volatile 
oil, but contains an acrid fixed principle. The chemistry of white mus¬ 
tard seeds appears not to have been certainly determined. In 1825, 
Henry and Garot discovered a substance in them— Sulpho-sinapisin — 
which, according to Husemann, has been variously designated as Sinapin , 
Sinapisin , Sinapinic Acid , etc., but has been demonstrated by Babo and 
Hirschbrunn to be an alkaloid which also exists in the seeds of the 
black mustard. Bobiquet and Boutron believe that the acrid fixed 
principle of white mustard is formed by a reaction between this and 
water in the presence of the emulsin. 

Therapeutics.— Mustard affords a most excellent material for the 
practice of mild revulsion. One great advantage it possesses is the 
ease with which it can be controlled,—all grades, from the mildest im¬ 
pression up to severe blistering, being at the will of the practitioner. 
It should be remembered, however, that the blister produced by it dis¬ 
charges but little, and is exceedingly sore and painful, as well as very 
slow and difficult of healing: so that, as an epispastic, mustard is in 
every way inferior to cantharides, and should not be employed. The 
black mustard is much stronger than the white, and must usually be 
diluted at least one-half (by the addition of flour or of flaxseed meal). 
The white variety may sometimes be employed pure, but generally it 
also should be reduced in strength. 

In many cases it is desirable to maintain for hours a mild, equable 
counter-irritant impression ; and this may be done by adding from one 
to three teaspoonfuls of mustard, more or less, to a poultice of flaxseed. 
A mustard poultice half-and-half black mustard, three parts to one 
white mustard, and flour, may generally be left on from twenty min¬ 
utes to half an hour without danger of blistering. Weaker prepara¬ 
tions may be used longer. A mustard plaster may be prepared like an 
ordinary poultice; but a very convenient method is to take a news¬ 
paper folded to a little larger than the desired size, and tear open the 
front piece so that it can be folded back like a flap, leaving one edge 
attached; next, to spread upon the thick portion the mustard, leaving 
the edges free, and then to close the flap upon it and fold the edges 
back to the desired shape: when done with, this plaster can be thrown 
away, and no rags are lost. The mustard draws well through the 


RUBEFACIENTS. 


813 


single layer of newspaper covering it, but is, I think, less apt to leave 
troublesome after-soreness than when employed in the usual manner. 
Charta Sinapis, U.S., or Mustard Paper , consists of black mustard 
mixed with solution of gutta-percha and spread upon stiff paper four 
inches square. It is not so good as the domestic plaster, because not so 
easily regulated as to power and size. 

Capsicum and the stronger spices afford excellent materials for rube- 
faction. Cayenne pepper is probably as strong as mustard, but is 
much less pleasant to handle, on account of the readiness with which 
it is diffused, and is much less frequently employed. Spice-plasters are 
useful when it is desired to make a steady, continuous mild impression, 
as in certain abdominal complaints. They may be made by the apothe¬ 
cary by means of the following recipe: Take of powdered ginger, §ii; 
powdered cloves and cinnamon, each, gi; Cayenne pepper, 5ii; tincture 
of ginger, fgss; honey, q. s.; mix the powders, add the tincture, and 
sufficient honey to make of proper consistence for a stiff cataplasm. 
The domestic spice-plasters are much more elegant and cleanly than 
those made on the above plan. They are to be prepared as follows. 
Take equal parts of ground ginger, cloves, cinnamon, and allspice, and 
one-fourth part of Cayenne pepper, and thoroughly mix them; then 
put the resulting dry powder into a previously-prepared flannel bag of 
the desired size, distribute the powder equably through the latter, and 
quilt it in,— i.e ., run lines of stitching across the bag, so as to confine 
the powder in little compartments. When used with common whisky 
or with alcohol, a plan which has seemed to me still more pleasant is 
to put two ounces of unground ginger, an ounce of unground cloves, 
cinnamon, and chillies, or African peppers, in a pint bottle, and pour 
the whisky upon them. After this has stood awhile, the liquor is to be 
put upon a piece of flannel of the proper size, and the latter is to be 
laid upon the part and covered with a larger piece of oiled silk, or else 
a piece of spongiopilin may be employed. If the strength of the 
preparation is too great, it can readily be reduced by dilution; if it is 
too little, it can as readily be increased by adding more of the spices, 
especially of the peppers. In many cases, when the tenderness is very 
great, the weight of the spice-plaster is objected to. Under these cir¬ 
cumstances the substitute here proposed is especially valuable. 

Oil of Turpentine is a very powerful rubefacient, capable, if applied 
to the skin for too long a time, of destroying the epidermis. It pro¬ 
duces, when properly used, simply an intense diffused redness. The 
most frequent mode of application is in the form of stupes , which should 
be made by dipping a piece of flannel, previously wrung out with warm 
water, into a cup of turpentine which has been warmed by setting it 
in hot water, and then wringing out all excess of the turpentine, and 
applying. These stupes may be left on from ten to thirty minutes, ac- 


814 


LOCAL REMEDIES. 


cording to the severity of the impression desired and the susceptibility 
of the patient’s skin. On some persons the least contact of turpentine, 
or even of its vapors, produces a most painful furuncular eruption. 
Where this idiosyncrasy exists, of course the remedy should never be 
used. The officinal liniment (Linimentum Terebinthince, U.S., Kentish 
Ointment ) is used as a stimulant application to burns. According to 
the U.S. Dispensatory, it should be applied as soon as possible after the 
reception of the burn, by covering the injured surface with pledgets of 
patent lint saturated with it, and should be allowed to remain on until 
the peculiar inflammation excited by the fire has subsided. 

Ammonia is a most efficient rubefacient, which in its general relations 
has been sufficiently discussed elsewhere. When great haste is required, 
it may be employed as an epispastic by applying a piece of common 
lint saturated with the strongest water of ammonia, and covering it 
with some impervious coating. Great care must be practised lest the 
ammonia act as an escharotic, since a too prolonged application may 
produce a deep slough. To raise a blister requires from five to ten 
minutes. On account of its cheapness and efficiency, ammonia is very 
largely used in extemporaneous liniments. In prescribing, it must 
always be borne in mind that there are two waters of ammonia,— Aqua 
Ammonite Fortior, U.S., with a specific gravity of 0.900, containing 
twenty-six per cent, of the gas, and Aqua Ammonite, U.S., with a spe¬ 
cific gravity of 0.960, containing about ten per cent, of the gas. The 
rubefacient action of ammonia is less permanent than that of turpen¬ 
tine. There is an officinal liniment (Linimentum Ammonite, U.S.), con¬ 
taining one part of the simple water to two parts of olive oil. 

Pix Burgundica, U.S., or Burgundy Pitch, is a concrete juice ob¬ 
tained by wounding the Abies excelsa, or Norway spruce, and Abies 
picea, or European silver fir,—lofty forest-trees of Middle and Northern 
Europe,—melting the product of the exudation with hot water, and 
straining. It is hard, opaque, brittle, of a feeble terebinthinate odor 
and taste, and contains resin and a minute amount of volatile oil. It 
is a mild rubefacient, which, in the form of plaster, may be kept applied 
for a long time in chronic bronchitis and in rheumatic affections of the 
trunkal muscles. The officinal plaster (Emplastrum Picis Burgundicce, 
U.S.) contains one-twelfth of its weight of wax. The Warming Plaster 
(Emplastrum Picis cum Cantharide , U.S.) contains one part of canthar- 
ides cerate to twelve parts of Burgundy pitch, and is a very decided 
counter-irritant, whose prolonged use will sometimes blister. 

Canada Pitch Plaster ( Emplastrum Picis Canadensis, U. S.), made 
from the concrete juice of the indigenous hemlock spruce ( Abies Cana¬ 
densis), acts precisely like Burgundy Pitch Plaster, and is used for the 
same purposes. 


FAMILY XIH.-ESCHAROTICS. 


Escharotics are drugs which are used to destroy diseased or sound 
tissue. Many of them exert a purely chemical influence, while others 
seem to destroy life by directly affecting the vitality of the part, and 
are said to act dynamically. Those which act chemically do so in sev¬ 
eral ways: some, like bromine, probably produce an intense corrosive 
oxidation, while others, like sulphuric acid, abstract the water. 

Escharotics are used for various purposes. Formerly they were 
employed to open abscesses; but in the very few cases in which the 
knife is not allowable, as in abscess of the liver, aspiration affords, 
without doubt, a much superior and, in hepatic abscess, much safer 
method. They are constantly applied to destroy unsound, harmful 
tissues and growths. Thus, they are used to remove the specific tissue 
of a chancre, or to kill a malignant or semi-malignant tumor. Another 
purpose which they fulfil is the destruction of poisoned wounds. In 
these cases they may in some instances destroy the poison itself, but 
at other times they simply prevent the absorption of the toxic agent 
by putting an end to the life-actions of the tissue containing it. It is 
hardly necessary to mention all the various cases in which caustics are 
employed to overcome the effects of poisoned wounds. Hydrophobia is 
a perfectly uncontrollable disease; but the thorough destruction of the 
wounded tissue at any time before the manifestation of the symptoms 
will probably prevent its occurrence, as it will certainly do if performed 
early. In malignant pustule, life depends upon the free early use of 
escharotics. Escharotics are employed to produce ulcerations which 
shall be the bases of issues; also, by destroying the exuberant granula¬ 
tions or the indolent surfaces of ulcers , to remove at the same time dis¬ 
eased tissue, afford protection to the parts below by forming an imper¬ 
meable surface, and exert such alterative action upon the part as shall 
modify for good the life-processes. 

It is evident that the choice of the caustic should depend upon the 
object to be attained. When large tumors are to be killed, or when it 
is all-important completely to destroy a poisoned wound, a powerful 
deep-reaching escharotic must be employed; but when the surface of an 
ulcer is to be filmed over, a caustic which acts superficially and forms 
a dense albuminous coating, as does nitrate of silver, is to be chosen. 

An observation of Drs. 1ST. A. Randolph and S. G-. Dixon {Med. 
News, Jan. 4, 1885) indicates that the pain produced by a caustic may 

815 



816 


LOCAL REMEDIES. 


be almost nullified by the use of cocaine. They find that the saturated 
solution of cocaine in nitric acid acts as powerfully as nitric acid, 
although much more slowly, and that the only sensation experienced 
during the production of even a deep eschar is a slight prickling. 

All of the more powerful of the escharotics, when taken internally 
in sufficient amount, act as violent corrosive poisons, producing ago¬ 
nizing pain in the oesophagus and hypogastrium, violent bloody vomit¬ 
ing, often purging of similar character, and finally collapse, deepening 
into death, which is sometimes preceded by convulsions. When the dose 
is not so large, the system may rally from the immediate effects of the 
poison, to succumb finally to the local lesions produced, or to struggle 
through a protracted convalescence to health, perhaps only to die years 
afterwards from organic stricture, caused by the ulcerations of the 
oesophagus or other of the digestive tubes. The first indication in poi¬ 
soning by one of these substances is to neutralize or chemically anti¬ 
dote the poison. Many, if not all, of the escharotics have some chem¬ 
ical antidote: with the alkalies, dilute acid, generally convenient in 
the form of vinegar; with the acids, alkalies, generally at hand in the 
shape of whitewash or of soap; with others, specific substances, which, 
as antidotes, should be at once exhibited. Opium should always be 
freely given, and the symptoms during and after the first poisoning be 
treated as they arise. 

Potassa, U.S. — Caustic Potash is officinally prepared by boiling 
liquor potassse until ebullition ceases and the potassa melts, when it is 
run into cylindrical moulds. It occurs in grayish semi-translucent 
sticks, about three inches long and as thick as a large goose-quill, very 
deliquescent when exposed to the air, and extremely soluble, except 
impurities (lime, oxide of iron, and carbonate of potassium), in both 
water and alcohol. When it is placed upon the skin it soon melts, and, 
as it does so, gives rise to a pain which increases until it becomes very 
intense, and continues until the power of the alkali is so lost that it 
can no longer reach through the tissue it has killed to the sound flesh 
below. Under the action of the escharotic the skin becomes of a dirty 
ashen-gray, and finally a slough is formed, with inflammation of the 
surrounding parts, and ulceration and detachment of the dead tissue 
in from six to ten days. The potash appears to act chiefly by ab¬ 
stracting the water, and, to some extent, by combining with the fatty 
and other portions of the tissues. Its slough being perfectly perme¬ 
able, and its power being but slowly expended by its own action, potash 
is one of the most thorough of the escharotics: it is, therefore, to be 
preferred when a very deep and decided influence is required, as after 
the bite of a rabid dog. It is somewhat uncontrollable in its action, 
and requires care in its use. The best method of application is as fol¬ 
lows. Take a piece of heavy adhesive plaster, and cut a hole in it of 
such size that, when the piece is warmed and properly placed upon the 


ESCEAROTICS. 


817 


skin, the part to be acted upon will he exposed while all around it will 
be protected. Then apply the plaster, and grease the outer surface of 
it, without allowing any of the oil to come in contact with the exposed 
central skin. Then lay the caustic potash upon the latter, and, when 
the action is believed to have extended deep enough, wash the part 
with dilute vinegar. 

Potassa cum Calce, U.S.— Vienna Paste is a grayish-white pow¬ 
der, composed of equal amounts of caustic potash and caustic— i.e., un¬ 
slaked—lime. It is not so active as caustic potash, but is less apt to 
spread and diffuse itself. It is to be mixed with sufficient alcohol 
to form a paste, and then applied like caustic potash. M. Piedagnel 
affirms ( Journal de Pharmacie et de Chimie, 3e ser., t. xxxiii.) that this 
caustic may be rendered nearly or entirely painless by mixing one part 
of muriate of morphine with three parts of the powder, and then by 
the addition of chloroform forming a paste that may be spread upon 
lead-plaster and so applied. In five minutes the skin under the appli¬ 
cation becomes of a dead-white color, and at the end of fifteen minutes 
is brown and carbonized. If the application be persisted in, the thick¬ 
ness of the eschar will become finally about equal to that of the layer 
of the paste employed. 

Acidum Arseniosum. —As a caustic, arsenic is energetic and powerful, 
but somewhat slow, and causes intense pain, with violent inflammation 
of the neighboring parts. It is stated to affect more rapidly morbid 
than normal structures, and is especially used for the destruction of 
malignant growths. It appears to act chiefly upon the vitality of the 
part, acting, when sufficiently diluted, as a powerful irritant, and when 
in a concentrated form producing an irritation so intense that life cannot 
endure it. Hence, probably, the reason of its affecting more rapidly 
morbid growths, which have a lower vitality than sound tissues. 

The great objection to the employment of arsenic is the possibility 
of its absorption in sufficient amount to cause constitutional symptoms: 
even death has resulted from its external use. Since absorption takes 
place much more rapidly in a healthy than in an intensely inflamed or a 
dead tissue, whenever arsenic is employed as a caustic it should be used 
so freely as to kill the tissues rapidly; and under no circumstances 
should it be applied to a fresh wound. 

Used in any way, arsenic is a hazardous caustic, and it ought to be 
employed only with the knowledge and distinct remembrance of this 
fact. Cancer , and perhaps some forms of semi-malignant ulceration, 
such as lupus, appear to be the only diseases which justify its use. Sir 
Astley Cooper's Arsenious Ointment consists of one drachm of arsenious 
acid, one drachm of sulphur, and an ounce of spermaceti cerate, and 
is to be allowed to remain in contact with the morbid growth for 
twenty-four hours. 


62 


818 


LOCAL REMEDIES. 


The Arsenical Paste of Frere Cosine and Eousselot, which is officinal 
in France, is composed of one part of arsenious acid, two of dragon’s 
blood, and two of porphyrized cinnabar, made into paste with mucilage 
when applied. There is no reason for believing that any of the almost 
innumerable substances which have been proposed as a basis for ar¬ 
senious pastes possess peculiar advantages: the only needful direction 
is to mix the caustic with from eight to ten times its bulk of inert ma¬ 
terial of such a nature as to make either an ointment or a paste, and to 
allow this to remain on for from eighteen to twenty-four hours. 

Zinci Chloridum, U.S.— Chloride of Zinc is made by the action of 
muriatic acid upon zinc. It occurs in broken fragments of a grayish- 
white color, translucent and waxy in appearance, of an acrid corrosive, 
or, when diluted, acrid astringent, metallic taste. It is extremely deli¬ 
quescent, fusible, volatilizable at a high temperature, and very soluble 
in both water and alcohol. Chloride of zinc is a very powerful caustic, 
producing, when applied in a concentrated form, intense pain lasting 
for six to eight hours, and a whitish eschar, which usually separates in 
from six to twelve days. Its penetrating powers are said to be a little 
less, and its action is more readily controlled, than that of potash; its 
absorption does not endanger life, as is the case with arsenious acid ; 
and it leaves a slough which is free from odor. 

Canquoin's Paste is made by mixing the chloride of zinc with flour 
and water. The strength varies according to the purpose, the weakest 
paste containing only one part of the caustic in six parts; the strongest, 
one part in three. When used, ten or fifteen drops of water are added 
to the paste, which is applied in layers, successive applications being 
required when a large tumor is to be destroyed. Anhydrous sulphate 
of calcium has been especially commended by Dr. A. Ure, as forming 
a drier paste with the escharotic and limiting its action more definitely 
to the site of application than any other substance. Concentrated 
alcoholic or watery solutions of the chloride of zinc are often used as 
caustics in cases of chancres and other small specific idcers, and are 
reputed to be efficient. They should be applied by means of little 
pledgets of lint. As the action of the chloride upon the skin is slow 
and very painful, whenever the cuticle over the part to be destroyed is 
sound it should be removed by means of blisters. By some surgeons 
the escharotic is introduced directly into the tumor to be destroyed. 
Thus, Maisonneuve makes a paste of one part of the chloride with 
three of flour and a little water, then cuts these into pointed strips or 
“ arrows” and dries them. He then thrusts these hardened bodies into 
the tumor—if necessary, first making incisions with the bistoury—in 
such a way that they lie close together and form a ring around the 
base of the tumor. A continuous slough is thus created, which cuts 
off the remainder of the mass from the sound tissue and causes its 
death. Sometimes Maisonneuve simply thrusts these arrows into the 


ESCHAROTICS. 


819 


body of the tumor and destroys it directly. The officinal solution 
(.Liquor Zitici Chloridi, U.S.) is used as a disinfectant. 

Hydrargyrum Chloridum Corrosivum, U.S.— Corrosive Sublimate is 
an escharotic of moderate power, which shares the dangers of arsenic, 
since death has followed its external use. In saturated solution it is 
much used as a caustic in chancres , but is scarcely equal to the solution 
of nitrate of mercury. In these cases it should be applied by means of a 
eamel’s-hair brush. Professor George B. Wood formerly recommended 
very highly that in onychia maligna a powder composed of equal parts 
of corrosive sublimate and sulphate of zinc intimately mixed should 
be sprinkled thickly over the diseased surface, and a pledget of lint 
thoroughly wet with laudanum laid thereon. There is severe pain for 
half an hour to an hour; but the dressings are not to be removed until 
eight or ten hours have elapsed. When the slough which is thus formed 
separates, a healthy granulating surface is left. 

Liquor Hydrargyri Nitratis, U.S.— Solution of Nitrate of Mer¬ 
cury is a nearly colorless, highly corrosive, acid liquid, having a spe¬ 
cific gravity of 2.165, and made by dissolving mercury, or its red 
oxide, in a large excess of nitric acid. It contains free nitric acid and 
the binitrate of the deutoxide of mercury. I do not know of its ex¬ 
ternal use ever having produced death; but it has caused salivation, 
and it is perfectly conceivable that its careless employment should lead 
to much more serious results: indeed, in the Lancet for Jan. 3, 1874, is 
reported a very serious case of poisoning by the application of the 
pernitrate to a space not bigger than a half-crown. It is rarely used, 
except for the purpose of destroying specific or cancerous ulcers. It is 
especially useful in chancres , to which it should be applied with a glass 
rod. In obstinate acne , a minute drop applied by means of a glass 
brush to the top of an indolent tubercle is said to destroy it with¬ 
out producing a scar. It has been largely employed by gynaecolo¬ 
gists in ulcerations of the cervix uteri. Its action is very prompt, and 
is moderately deep ; the pain is severe, but transient. 

Acidum Sulphuricum. — Sulphuric Acid is a powerful escharotic, and 
was formerly used extensively for destroying even large growths. For 
this purpose the strongest acid is mixed with charcoal, so as to make 
a thick, manageable paste. Before the application of this, the skin 
should be removed by a blister. 

Acidum Nitricum. — Nitric Acid is a powerful caustic, which is never 
employed to destroy large growths, but is a favorite application to 
chancres , to syphilitic , phagedenic , and other unhealthy ulcers , and to 
condylomata and other small dermal growths. It is applied by means 
of a glass rod or a splinter of wood. A drop or two is usually amply 


820 


LOCAL REMEDIES. 


sufficient j and when the action has gone far enough, the part should 
be washed with soap-suds, which at once neutralizes the acid. 

Acidum Muriaticum. — Muriatic Acid is capable of acting as a caus¬ 
tic, but is less powerful than either sulphuric or nitric acid, and is rarely 
used. 

Acidum Chromicum. — Chromic Acid occurs in anhydrous acicular 
crystals, of a deep-red color, and an acid, metallic, corrosive taste. 
They are very deliquescent, melting down, when exposed to the air, 
into a deep-red solution. Chromic acid is a very active oxidizer, and 
when mixed with organic matter rapidly alters it, and if in slight ex¬ 
cess will dissolve almost any form of tissue. It is no doubt in this way 
that it acts as an eseharotic. It is very much used to destroy condylo- 
mata and other dermal growths , and doubtless would be efficient in cases 
of larger tumors. In superficial affections it is best applied by means 
of a glass rod, the liquid formed by the spontaneous deliquescence of 
the crystals being used. Chromic acid is sometimes prescribed dissolved 
in, or made into a paste with, glycerin, but it is stated that in mixing 
the two great care must be taken to add the liquid slowly drop by drop, 
as otherwise there is danger of an explosion ( Phila . Med. Times , iv.). 
Care must be exercised in the free use of chromic acid,* as it is a violent 
poison, and has produced death when employed locally ( Strieker's Jahr- 
bucher, 1877, p. 139; also Schmidt's Jahrb., 1884, cci. 129). 

Bromum, U.S.— Bromine is a dark-red liquid which has a very power¬ 
ful, disagreeable, chlorine-like odor, and at ordinary temperatures emits 
exceedingly acrid, pungent fumes. It is sparingly soluble in water, 
more soluble in alcohol, and still more so in ether. When brought into 
contact with organic matter, it oxidizes and completely destroys it with 
great rapidity. On account of this property and of its liquid form, 
bromine is one of the most severe, thorough, and rapid of all the caus¬ 
tics. It has not been much employed to destroy morbid growths, but 
during our late war was found to be the most efficient of all the appli¬ 
cations tried in hospital gangrene. After most of the slough had been 
cut away, the caustic was applied pretty freely to the living tissue by 
means of a glass rod. The pain was very severe, but transient. 

Sulphate of Zinc and Sulphate of Copper are feeble escharotics, never 
used to destroy sound tissue. Burnt Alum belongs in the same cate¬ 
gory, but is probably a little more feeble. All three of these drugs are 
used to destroy exuberant granulations in ulcers. 


* For experiments as to its effect on animals, see Arch./. Exper. Path. u. Pharm., vi .; also 
Strieker’s Jahrb., 1877, p. 139. 



FAMILY XIY-DEMULCENTS. 


These are bland substances, which form more or less gummy or 
mucilaginous solutions in water, capable of exerting a calming or sooth¬ 
ing influence upon inflamed surfaces. Without doubt water itself is 
the demulcent par excellence ; but the remedies here discussed do seem 
to enhance its power. It has been claimed for these medicines not 
only that they soothe surfaces to which they are immediately applied, 
but also that taken internally they relieve irritation in distant organs. 
As, however, all of them are complex vegetable products, as many of 
them are staple articles in the world’s food, and as none of them have 
been detected in the blood or the secretions, it cannot be allowed that 
they reach distant parts through absorption into the blood. What is 
certainly true of some of them is probably true of all,— i.e., digestion 
of them occurs in the prirme vise. The relief which undoubtedly fol¬ 
lows their use in certain affections of parts which they can reach only 
through the circulation is probably in great part, if not altogether, due 
to the large quantities of water with which they are administered, 
which, passing through the body, lessen the concentration, and hence 
the acridity, of the urine and other secretions. 

Clinically, demulcents are useful as local applications in all forms of 
acutely-inflamed surfaces, and they are taken internally in acute inflam¬ 
matory conditions of the alimentary canal. In slight bronchial irritation 
they are often of service, especially when allowed to dissolve slowly in 
the mouth: used in this manner, they not only exert an influence upon 
the mucous membrane of the mouth, but very probably find their way 
also into the respiratory passages. 

ACACIA—GUM ARABIC. U.S. 

A gummy exudation from Acacia vera and other species of Acacia, 
small trees growing in Northern Africa, Senegambia, Guinea, etc., the 
Cape Colony, and Australia. Gum arabic occurs in roundish or irreg¬ 
ular pieces, more or less transparent, hard, brittle, varying in color 
from white or yellowish white to red, or even deep orange brown. It 
consists of a peculiar principle, Arabin. united with about three per 
cent, of lime, potash, and magnesia. According to Husemann, pure 
arabin is an amorphous substance, glassy and transparent when dry, 
but milk-white when moist, and having a feeble acid reaction, with the 
power of uniting with bases. In the plant, arabin, like other gums, 



822 


LOCAL REMEDIES. 


appears to be formed by a retrograde metamorphosis of cellulose. In¬ 
deed, Wigand declares that the flesh and even the hard endocarp of the 
plum can undergo this metamorphosis. The same investigator affirms 
that bassorin is a first product of the change, and is, by a continuation 
of the process, converted into arabin. On account of its solubility 
and pleasant taste, gum arabic is often used as a demulcent in irritation 
of the fauces and in angina. It is sometimes employed as an addition 
to drinking-water in fevers, and is believed to have slight nutritious 
properties. Its chief use, however, is in Pharmacy, in the making of 
emulsions, pills, etc. The mucilage (.Mucilago Acacice ) is officinal. 

Tragacantha, U.S.— Tragacanth is the concrete juice of Astragalus 
verus, a small shrub of Asia Minor. Tragacanth occurs in large, 
whitish, horny, waved flakes, or sometimes in filamentous pieces. It is 
odorless and nearly tasteless. Introduced into water it does not dis¬ 
solve, but swells up into a soft paste. One hundred parts of it contain, 
according to Guerin, 53.3 parts of arabin, 33.1 parts of bassorin, and 
2.5 parts of inorganic ash. Bassorin is a gummy principle, at once 
distinguished from arabin by its not dissolving in water, but simply 
swelling up into a pasty mass. Tragacanth is used only in the manu¬ 
facture of troches and in suspending heavy powders, for which purpose 
the difficulty of its solution and the extreme viscidity of its mucilage 
especially fit it. Its mucilage (Mucilago Tragacanthce) is officinal. 

Ulmus, U.S.— Slippery Elm is the inner bark of Ulmus fulva, a 
large indigenous tree. The bark is of a yellowish-white or tan color, 
fibrous, yet when dry somewhat brittle, and occurs in long, flat strips 
or pieces one or two lines thick. It is pleasantly mucilaginous when 
chewed. It contains a large quantity of a peculiar mucilage, which it 
yields freely to water. Its infusion is sometimes taken in large quanti¬ 
ties in inflammations of the intestines , as a demulcent laxative; but its 
chief use is as an external application. When ground into powder, 
slippery elm makes a very excellent soothing poultice. The mucilage 
(.Mucilago Ulmi ) is officinal. 

Cetraria, U.S.— Iceland Moss is the fronds of a lichen, Cetraria 
islandica, growing on rocks in Iceland and in most of the northern 
portions of the world. It is said to be abundant in the mountains of 
New England. The foliaceous, dry, shining, lobed, and laciniated fronds 
are about four inches long, of various intermixed colors, gray, brown, 
and red, of a mucilaginous, bitter taste. Iceland moss contains a pecu¬ 
liar starch-like principle, lichen starch, and a bitter principle. It is in¬ 
odorous, and has a mucilaginous, bitter taste. It yields to cold water 
its bitterness; to boiling water all of its virtues. Cetrarin, or Cetraric 
Acid , is the bitter principle, which may be obtained as a snow-white 
mass of interlaced acicular crystals. It unites with alkalies to form 


DEMULCENTS. 


823 


salts. With it in the lichen is associated in small quantities lichstearic 
acid. Lichenin, or Lichen Starch, the mucilaginous, nutritive principle 
of Iceland moss, differs from ordinary starch in not being deposited in 
granules within the cells, but in layers or irregular masses between the 
cells, or indeed forming the walls themselves of the cells (De Bary, 
Hofmeister's Handb. der physiolog. Botan., Bd. ii. p. 255). In cold water 
it swells up without dissolving; in hot water it dissolves, and on cool¬ 
ing condenses into a jelly. With iodine it strikes a yellow, green, or 
sometimes rather faint blue, color. It is found in very many lichens; 
also in many species of sea-weed, notably in the so-called Corsican moss. 
Iceland moss has enjoyed some reputation as a demulcent in pectoral 
complaints. From its bitter principle, it is probably somewhat tonic, 
and its lichenin is probably about equal to ordinary starch as a nutrient. 
When prepared as an article of diet, in the form of jelly, the bitter 
taste should be removed by soaking for some hours in a very weak cold 
alkaline solution, and afterwards for a little while in cold water. 

Chondrus, U.S.— Irish Moss, or Carrageen. —The fronds of Chondrus 
crispus, a sea-weed growing on the coast of Ireland, and also on the 
northern coast of the United States, where it is now gathered in large 
quantities. The fronds are purplish red,—but, as kept in the shops, 
bleached by washing in fresh water, whitish, and translucent,—cartila¬ 
ginous, slender, much branched, swelling up but not dissolving in water, 
and having a slightly saline taste. Their virtue depends chiefly upon 
a starch- or gum-like principle, Carrageenin, which is distinguished from 
starch by not turning blue with iodine, and from gum by not precipi¬ 
tating from its watery solution on the addition of alcohol. Chondrus 
also contains a notable proportion of a vegetable albumen. 

Carrageen, being demulcent and nutritious, is employed as an article 
of diet in those cases requiring food of such character, and may be 
used instead of arrow-root. It is to be prepared by first soaking for 
ten minutes in cold water, and then boiling from half an ounce to an 
ounce of it (according to the desired consistency) in a pint and a half 
of water down to a pint, sweetening and flavoring to taste. Milk may 
be substituted for water. 

Glycyrrhiza, U.S .—Liquorice Root is the root of Glycyrrhiza glabra, 
a native herb of Southern Europe. It occurs in long, cylindrical pieces, 
from a few lines to more than an inch in diameter, brownish exter¬ 
nally, and yellowish within. Its fracture is fibrous, its taste sweet and 
mucilaginous, its odor none. Its active principle is Glycyrrhizin. This 
is a sweet, neutral substance, differing from the sugars in not being 
converted by nitric acid into oxalic acid, and by its inability to undergo 
the vinous fermentation. Liquorice root is very largely used as a 
demulcent in pectoral complaints, and, on account of its pleasant taste, 
as a means of disguising or of flavoring medicines. In the form of 


824 


LOCAL REMEDIES. 


glycyrrhizin it is said to conceal almost entirely the bitter taste of 
quinine and similar substances. It is used almost exclusively in the 
form of the extract (.Extractum Glycyrrhizce , U.S.), known as Liquorice. 
The Mistura Glycyrrhizce Composita , U.S., or Brown Mixture , contains 
paregoric, antimonial wine, and sweet spirit of nitre, and is much used 
as a domestic remedy in “ colds" and the early stages of mild bronchitis. 
The dose for an adult is half a fluidounce to a fluidounce every three 
hours; for a child three years old, a teaspoonful. The pure extract 
(.Extractum Glycyrrhizce Purum, U.S.) and the fluid extract (.Extractum 
Glycyrrhizce Fluidum, U.S.) are excellent preparations. Glycyrrhizinum 
Ammoniatum , U.S., is a very elegant demulcent preparation, which, 
however, is incompatible with acid or alkaline solutions: its dose is 
from five to ten grains. The compound liquorice powder ( Pulvis Glycyr¬ 
rhizce Compositus , U.S.) contains senna and washed sulphur. It is an 
elegant laxative, acting, usually mildly and without the production 
of pain, in doses of one to two teaspoonfuls. 

Linum, U.S., or Flaxseed , is the seed of Linum usitatissimum, or 
common flax, and contains large quantities of mucilage and of oil: its 
compound infusion is much used internally. It is often made with 
boiling water; but the application of too much heat causes the ex¬ 
traction of more or less of the oil, and thereby renders the preparation 
less palatable. The infusion should never, therefore, be boiled during 
its making. The addition of lemon and sugar renders it more pala¬ 
table. It may be drunk ad libitum in pectoral catarrhs , in enteritis 
and dysentery , and in irritation of the kidneys or the urinary passages. 

Medulla Sassafras, or Sassafras pith, yields a delicate mucilage 
much used in diseases of the eye ( Mucilago Sassafras Medullce, U.S.). 

Althea, U.S.—The roots of Althiea officinalis yield a bland muci¬ 
lage, their decoction is sometimes given in irritated states of the 
stomach and bowels, and their syrup (Syrupus Althcece , U.S.) is used as 
a vehicle. 

The seeds of the quince (Cydonium , U.S.) readily yield to water a 
thick mucilage ( Mucilago Cydonii, U.S.). 

Tapioca is the fecula of the root of Janipha Manihot, a native of 
South America. There are two varieties of the tapioca plant,—the 
sweet and the bitter cassava. The latter is in its fresh state poisonous, 
from the prussic acid which it contains, but yields most, if not all, of 
the tapioca of commerce. The tapioca is obtained by allowing the ex¬ 
pressed juice to stand, separating the powder which deposits, washing, 
and drying by heat, owing to the action of which the starch is rendered 
partially soluble in cold water. It is in irregular, hard and rough, 


DEMULCENTS. 


825 


nearly tasteless grains, which the microscope shows to be composed of 
raptured starch-granules. 

Maranta ( Arrow-root ) is a fecula or starch, obtained from the rhi¬ 
zome of Maranta arundinacea, a native of the West Indies. Arrow- 
root is produced in the West Indies, in Africa, and in the Southern 
United States, especially Florida. The most esteemed variety is that 
which comes from the island of Bermuda. It is obtained in the usual 
method by beating the root-stocks into a pulp, and the use of flowing 
cold water. It occurs as a very light, tasteless, and odorless white 
powder, which the microscope shows to be composed of ovate, oblong, 
or irregularly-convex granules, from the seven-hundred-and-fiftieth to 
the two-thousandth of an inch long, marked with very fine rings and 
with a circular hilum, which cracks in a linear or stellate manner. 
Arrow-root is often adulterated with other starches, which are best 
detected by the microscope. 

For methods of preparing arrow-root and tapioca, see page 32. 

Sago is a fecula obtained from the pith of Sagus Rumphii and other 
sago palms of Sumatra and the neighboring regions. It is first pre¬ 
pared in the usual manner, and then formed into a paste with water, 
rubbed into grains, and dried. Pearl Sago occurs in hard, roundish, 
somewhat translucent or sometimes opaque grains, about the size of a 
pin’s head. Common Sago is in larger and browner grains, often mixed 
with some powder. It is composed of oval or ovate, often truncate and 
muller-shaped, often much broken, starch granules. It is used exclu¬ 
sively as an article of diet, forming a jelly, which is best prepared as 
follows: Wash the sago well in cold water; put a small teacupful of it 
to soak in half a pint of water over-night, and in the morning put this 
mixture into one pint of hot water; squeeze into it the juice out of a 
thinly-pared lemon, and allow to simmer slowly for twenty minutes; 
then sweeten, add wine according to taste or the exigencies of the case, 
then pour into moulds to cool. 

Hordeum. —Under the name of Hordeum , or Barley , the United 
States Pharmacopoeia recognizes the decorticated seeds of the common 
barley, the pearl barley of commerce. They contain starch and muci¬ 
lage, and the decoction (. Decoctum Hordei ) was formerly officinal. Barley- 
water is used as a nutritious, demulcent drink in fevers and inflammatory 
conditions, especially when the gastric mucous membrane is involved. 
The U.S. Pharmacopoeia of 1870 directed that it should be prepared as 
follows: “ Take of barley two troyounces ; water a sufficient quantity. 
Having washed away the extraneous matters which adhere to the bar¬ 
ley, boil it with half a pint of water for a short time, and throw away 
the resulting liquid. Then, having poured on it four pints of boiling 
water, boil down to two pints, and strain.” 


FAMILY XV—EMOLLIENTS. 


True emollients are perfectly bland, fatty substances which, when 
applied to the skin, soften it and render it more pliable. The action of 
these remedies is largely mechanical, and they probably soften the derm 
in precisely the same way as they affect a raw hide or a piece of leather. 
They are therefore especially useful when the skin has a tendency to 
crack or to chap. Whenever surfaces become sore by attrition, or, in 
other words, chafe, emollients are also useful mechanically. They often 
afford relief in simple inflammations of the skin under such circum¬ 
stances that their action cannot be explained as purely mechanical: 
indeed, they seem to exert a dynamic influence upon the nutrition 
of the parts concerned. To the best of our present knowledge, the 
oxygen or other constituent of the air acts as a stimulant to exposed 
surfaces and increases inflammations there present; and it is believed 
that fatty matters do good by keeping out the air. If this be so, the 
apparently dynamic influence of fatty matters is, after all, mechanical. 
Be these things as they may, clinical experience has demonstrated 
that fatty matters are of very great value in the treatment of super¬ 
ficial inflammations. It must be borne in mind that the blandest fat, 
when it becomes rancid, is very irritating, and will do far more harm 
than good, so that the strictest attention must be paid to the con¬ 
dition of the fatty material employed. Any perfectly bland oily sub¬ 
stance may be used as an emollient. Mutton suet and goose-grease are 
famous in domestic medicine, but are simply valuable because, if well 
prepared, they are less apt than some other fats to become rancid. It 
cannot be allowed that there is any difference in fats, unless it be in 
penetrating power: a very hard fat is of course not so readily applied 
as a softer one, and therefore only such fats as freely melt, or at least 
become very soft, at the temperature of the body, are to be used. Com¬ 
mon Lard (Adeps , U.S.), when freed by washing from the salt which it 
commonly contains, is a mild fat, melting at the temperature of the 
body. It is enormously used in pharmacy. Cacao Butter ( Oleum Theo- 
bromce, U.S.) is an absolutely bland vegetable fat, which is a firm solid 
at ordinary temperatures, but melts with the heat of the body, and 
is consequently very largely used in the preparation of suppositories, 
both officinal and magistral. Spermaceti (Cetaceum, U.S.) is employed 
to give consistence to ointments, as is also wax ( Cera alba , or white ivax, 
and Cera flava, or yellow wax , U.S.). Cold Cream ( TJnguentum Aquae 
826 



EMOLLIENTS. 


827 


Rosce, U.S.), containing oil of sweet almonds, spermaceti, white wax, 
and rose-water, is one of the most elegant of the officinal emollients. 

Lanolin is a fat obtained from the wool of sheep, which is said to 
contain, on an average, forty-five per cent, of it. It was first recom¬ 
mended by Dr. Oscar Liebreich as a basis for ointments or preparations 
to be applied to the surface of the skin. It is entirely free from irritant 
properties, has the power of taking up a large amount of water without 
losing its unctuousness, and is asserted to be absorbed through the 
skin much more readily than other fats. In the experiments of Dr. 
Patschkowsky (JPharm. Zeit., 1885), half an hour after inunction with 
lanolin and iodide of potassium the iodine was recovered from the 
urine, while officinal iodide of potassium ointment yielded negative re¬ 
sults. This has been confirmed by Kaspar (Deutsche Med. Woche?ischr., 
Dec. 1885), but Ritter and Pfeiffer obtained contrary results, and in a 
considerable series of experiments were unable to perceive that lanolin 
had any superiority over other fats in promoting absorption. The 
fact, moreover, that lanolin is largely the secretion of sebaceous folli¬ 
cles, contains an abundance of cholesterin, and is of the nature of a 
waste product, which is intended, not for absorption, but for the keep¬ 
ing soft of the skin and its appendages, indicates very strongly that 
it will yield itself, and medicinal properties with which it may be 
impregnated, less readily to absorption than do other fats. 

GLYCERINUM—GLYCERIN. U.S. 

This is a thick, syrupy liquid, colorless, free from odor, and of a 
sweet taste. It was originally prepared by heating together a metallic 
oxide and ordinary fats, as in the manufacture of lead-plaster. Chemi¬ 
cally speaking, it belongs to the alcohols, and is known according to 
the recent nomenclature as propenyl alcohol. It is always set free dur¬ 
ing the process of saponification, when the stearic or other acids of the 
fat unite with some base to form salts known as soap. Consequently, 
glycerin always forms a considerable part of the soap-maker’s waste; 
but in this it is so mixed with impurities that until recently it was 
valueless. Now, by means of certain patent processes, the glycerin is 
said to be obtained pure from the waste products of soap-factories. 
The great bulk of the glycerin in commerce is made by the direct 
decomposition of fats by heated steam. 

Under certain circumstances, not well understood, glycerin forms 
hard, brilliant crystals. In its usual liquid form it mixes in all propor¬ 
tions with water and alcohol, and itself dissolves iodine, bromine, the 
alkalies, tannic and other vegetable acids, a large number of neutral 
salts, salicin, and other organic principles. 

Glycerin does not evaporate upon exposure, but is very hygroscopic, 
and absorbs water from the air. When pure, it is incapable of be¬ 
coming rancid or of fermenting spontaneously. The acrid glycerin 


828 


LOCAL REMEDIES. 


formerly so abundant, and still met with, owes its irritant properties 
to contaminating substances, especially, it is said, to oxalic and formic 
acids. The former of these substances is apt to be created by the action 
of the sulphuric acid used during the purification of the glycerin, the 
latter by the reaction between the oxalic acid and the glycerin. 

Physiological Action. —When large doses of glycerin (in the dog 
eight or more parts per thousand by weight) are injected subcutane¬ 
ously, death is produced in a period varying, according to the dose, 
from one hour to several days. The symptoms are loss of muscu¬ 
lar strength, lethargy, bloody urine, vomiting, dryness of the mucous 
membrane, with marked thirst, fall of temperature, gradual extinction 
of both respiration and circulation, and finally convulsions and coma 
(Dujardin-Beaumetz and Audije, Bull. Therap ., xci. 62). The convul¬ 
sions occur more early and severely when large doses are employed, 
and are then said to be tetanic, and to be accompanied with a decided 
rise of temperature. The fall of temperature is, even in the milder 
cases, present only late in the poisoning, and is sometimes, if not always, 
preceded by a rise. After death intense congestion, with more or less 
softening of the tissue, is found in the lungs, kidneys, and intestines. 
In man no symptoms of poisoning have ever been produced by glyce¬ 
rin, the largest single amounts ingested—an ounce or so—having no 
perceptible effect other than that of a laxative. 

Catillon claims that glycerin administered in small continuous doses 
exerts a decided effect upon nutrition (Bull. Therap., xcii. 130; Arch, 
de Physiol. Norm, et Path., 1877). In his experiments he found that 
eight grains given daily to guinea-pigs produced a very marked gain in 
weight, with a lessened excretion of urea. In man an ounce daily also 
produced in the elimination of urea a decided diminution, which was 
not increased by increasing the doses of glycerin. The appetite in 
many cases was, after a little time, much improved, and then the in¬ 
creased ingestion of food produced an increased elimination of urea. 
The fact that an increase of food was permitted in these experiments 
shows, however, that the conditions of experimentation were not rigid 
enough to allow much weight to be attached to the result; and the 
relation of glycerin to the elimination of urea has been investigated 
by L. Lewin (Zeitschr. f. Biol., xv.), by N. Tschirwinsky (Ibid.), and by 
I. Munk (Virchow's Archiv, lxxvi. 130), with somewhat contradictory 
results. Of these experiments the most extensive are those of Munk, 
who seems to have used all proper precautions, and found that glycerin 
has no effect upon the elimination of urea or the general bodily nutri¬ 
tion. The results reached by Lewin correspond with those of Munk. 
Tschirwinsky omitted fatty materials from the food, and found that 
while at first the elimination of urea was diminished, it afterwards, 
under the use of very large doses of glycerin, was increased. With our 
present evidence it must be considered most probable that glycerin has 
no controlling power over the waste of nitrogenous tissues. 


EMOLLIENTS. 


829 


Glycerin is absorbed from, the alimentary canal, and when freely 
administered is in part eliminated, and in part burnt up in the system. 
Both Ustimowitsch ( Archiv f. d. Ges. Physiolog., xiii. 453) and Plosz 
(Ibid., xvi. 153) found a substance in the urine which they believe to 
be a derivative product of glycerin, while Catillon proved that it is 
not eliminated by the skin or, even when it purges, by the intestines. 
Catillon and Lewin recovered from the urine only a small propor¬ 
tion of that ingested, Tschirwinsky only 8.7 per cent., while Ludwig 
Arnschink ( Sitzungsb. Gesellschaft Morphol. Physiol. Munchen , 1886, ii., 
also Zeitschr. fur Biolog., xxiii. 413) found that not more than thirty 
per cent, escapes from the body. In its oxidation within the body 
glycerin must yield heat. It probably has food-value in it, being able 
to replace to some extent true fatty carbohydrates. According to the 
calculations of Arnschink, two hundred and nineteen parts of it are 
about equivalent to one hundred parts of fat. Although it is probably 
more readily oxidized than are ordinary fatty matters, it is evidently 
of little real value as a nutrient in the treatment of disease. 

According to Fuchsinger, the bloody urine produced by poisonous 
doses of glycerin contains an abundance of the coloring-matter of 
the blood, but no free corpuscles ( Pfluger's Archiv , xi. 502). Yery 
interesting in connection with the use of glycerin in diabetes is the 
assertion of Fuchsinger ( Pfluger's Archiv, xii. 501; Centralbl. f. Med. 
Wiss., 1877), that in rabbits slightly poisoned with glycerin no sugar 
appears in the urine after the “diabetic puncture.” The experiments 
of Eckhard gave, however, a contrary result ( Centralbl. f. Med. FPi'ss., 
1876, p. 273), and Catillon affirms that given in very large continuous 
doses glycerin increases the amount of sugar in the blood. 

Therapeutics. —Locally applied, glycerin is usually unirritating, 
and it is much employed as an emollient. The chief disadvantage that 
attends its use is its stickiness; on the other hand, its non-volatility 
and its hygroscopic properties give a persistency to its action which is 
often very advantageous. It enters largely into the composition of 
popular emollient ointments, or “ creams,” as they are called, and is 
often used itself for chapped hands, excoriations, and similar troubles. 
It is also employed by dermatologists to some extent in chronic eczema ; 
in seborrhcea, whether affecting the hairy scalp pr other parts, it is as¬ 
serted to be especially useful, softening the masses of secretion, and, 
used in conjunction with such remedies as borax, zinc, and acetate of 
lead, diminishing the amount of secretion. When there is a want of 
sebaceous secretion, it is said also to act efficiently; in scabies, pruritus, 
and even psoriasis, glycerin is used, diluted with water, as a vehicle for 
more active remedies. Upon the mucous membranes glycerin acts very 
much as it does upon the skin, and diluted with water is very useful in 
coryza, and even, by enemata, in dysentery; in croup or laryngitis it may 
with advantage be applied freely by means of a large camel’s-hair 
brush to the orifice of the larynx, so as to run into the latter. In lax- 


830 


LOCAL REMEDIES. 


ative doses it is asserted to be very effective in hemorrhoids. It also 
forms an excellent basis for mouth-washes; or a paste may be made 
with it and borax, or similar substance, for use in ulcerations of the 
same cavity. The list of diseases in which this remedy is employed 
might be very much lengthened; but the examples already given are 
sufficient to indicate the range of its application as an emollient and 
as a vehicle. There are certain persons upon whose skin and mucous 
membranes even the purest glycerin seems to act as an irritant. This 
influence is most intense when the glycerin is nearly or entirely free 
from water. It is, however, discernible even when the remedy is much 
diluted, and often inhibits its use. The existence of this idiosyncrasy 
to glycerin can be determined only by trial. 

When administered internally in doses of one or two ounces, 
glycerin acts as a gentle but very uncertain laxative. I do not think 
that a single dose has any other perceptible effect. It was long ago 
proposed as a substitute for cod-liver oil in cachectic diseases, but failed 
to acquire reputation. Nevertheless, the results of Catillon would seem 
to demand for it more extensive trial. That observer states the proper 
amount of it to be half an ounce to an ounce in the course of the day, 
in three doses. It has also been proposed and highly commended in 
diabetes.* It appears to be harmless in this affection, and therefore 
may be used as a sweetening-material for coffee, tea, and other bever¬ 
ages ; but there is no reason to believe that it exerts any control over 
the disease. The most important internal use of glycerin is as a harm¬ 
less substance which has the power of disguising nauseous medicines. 
In this way it may be employed with castor oil, in emulsions of turpen¬ 
tine, in solutions of iron, and in various mixtures. It seems, as it were, 
to envelop the medicinal substances and prevent their acting on the 
palate. Plasma or Glycerite of Starch ( Glyceritum Amyli , U.S.) is often 
used as a protective; Glycerite of Yolk of Egg (Glyceritum Vitelli, U.S.) 
is chiefly employed in making emulsions. 

SACCHARIN.! 

Saccharin is a substance discovered by Dr. Fahlberg in 1879. Its 
chemical relations are too complex for discussion in a work like the 
present. It occurs as a white powder composed of irregular crystals, 
very slightly soluble in water, readily soluble in glycerin, alcohol, and 
ether. Its watery solution has a distinctly acid reaction, and it forms 
salts. Its most remarkable property is its sweet taste, which is said to 
be three hundred times more intense than that of sugar, so that if one 
grain of it be dissolved and neutralized in about ten pints of water its 
presence can still be recognized. A. Mosso and V. Aducco ( Archives 


* For literature and discussion of point, see Ziemasen’s Encyclopaedia, vol. xvi. 

! The present is probably as good as any other place in the book to notice a substance 
whose use in practical medicine depends upon its lack of medicinal properties. 



EMOLLIENTS. 


831 


Ital. de Biolog., 1886, vii.) find that when a solution of saccharin is ren¬ 
dered neutral with soda frogs will live in it for months; also that the 
injection of concentrated solutions of saccharin into the cellular tissue 
has no influence on the batrachian. Six hundred grains given to a dog 
during ten days caused no alteration in the weight or general health 
of the animal. A careful study failed to detect any change in the urine 
as to the daily excretion of water, urea, hippuric acid, sulphuric acid, 
or phosphoric acid. The chlorides seemed to be somewhat increased. 
The saccharin escaped unchanged from the kidneys, rendering the urine 
very sweet, and having a notable effect in delaying its putrefaction. No 
saccharin could be found in either the milk or the saliva of a nursing 
woman to whom it was administered, and a dose of seventy-five grains 
caused no symptoms in man. These statements are confirmed by Sal- 
kowski ( Virchow's Archiv, cv. 46), and are in accord with the clinical 
studies of Dresehfeld ( Birmingham Med. Journ ., 1886, p. 409), Leven- 
stein {Journ. Soc. of Chern., 1886), and other clinicians, who state that 
when taken in food by diabetics saccharin has no sensible effect either 
upon the general system or the urinary secretion. The value of sac¬ 
charin is simply for the purpose of replacing sugar in diabetes, obesity, 
and other diseases in which sugar is counter-indicated. Our present 
evidence shows that it may be used freely as an article of diet. As it 
does not dissolve readily in ordinary food-preparations, a solution of it 
in glycerin should be prepared for table use. 

Petrolatum, U.S. — Under the name of vaseline, cosmoline, etc., 
various yellowish, fat-like substances are sold which are obtained by 
distilling off the more volatile portions of American petroleum. The 
consistency of these substances depends upon the extent to which the 
distillation has been carried. The base of them all is paraffin. In the 
ordinary form they melt at about the temperature of 104°. Liquid 
cosmoline is a fluid substance obtained by a very incomplete distillation. 
Petrolatum of the United States Pharmacopoeia is directed to have a 
specific gravity of 0.835 to 0.860. Cosmolines are insoluble in water, 
scarcely soluble in alcohol, but soluble in ether, chloroform, bisulphide 
of carbon, oil of turpentine, benzin, and fixed or volatile oils. By heat 
they should be completely volatilized without emitting acrid vapors. 
They do not become rancid, are absolutely free from irritating proper¬ 
ties, and are much used as a basis for ointments and as emollient appli¬ 
cations to the skin. Petrolatum has been taken and administered by 
Dr. Archer Randolph in doses of a drachm or more. He found it to 
have no general action on the system, but to act locally upon the mu¬ 
cous membrane of the alimentary canal much as it does on the skin, 
allaying irritation, and provoking soft faecal discharges. 

Poultices. —Under the head of Emollients I shall also speak of 
poultices, which are moist, soft, scarcely adhesive, perfectly bland plas- 


832 


LOCAL REMEDIES. 


ters, used to a very great extent to combat superficial inflammation. 
Poultices are much more powerful agents than the true fatty emollients, 
and are correspondingly more capable of being abused: the results of 
such abuse will be spoken of directly. A poultice may, of course, be 
stimulating and irritant if made of such a substance as mustard; but 
the emollient or true poultice is prepared out of some bland material 
which is totally free from action upon the skin. I do not think that 
there is any difference whatever in the action of the various substances 
usually employed in the preparation of poultices, the latter depending 
for their remedial powers solely upon the warmth and water which 
they contain. Water, when pure and of a temperature approximating 
that of the body, is a sedative, checking all action, possibly by a direct 
influence, but probably by the merely mechanical acts of dilution of 
the pabulum and of separation of the germinal granules. It is also a 
relaxant, rendering all tissues soaked in it soft and yielding. 

Poultices are sometimes applied in the early stages of phlegmonous 
and other superficial inflammations, for the purpose of checking the 
morbid action. Their influence is in such case simply one of sedation, 
and they are certainly not so efficient as the cold-water dressing. They 
are, however, especially useful in the advanced stages of inflammation, 
when suppuration has already commenced or is about to set in. Clini¬ 
cal experience has demonstrated that they now favor the formation of 
pus. It is hardly worth while to discuss how they do this, so long as 
the natural method in which pus is produced is a matter of dispute. 
If, as Cohnheim believed, pus is composed solely or largely of out- 
wandering white blood-corpuscles, it is evident that the relaxing influ¬ 
ence of a warm poultice will greatly facilitate the escape of these 
bodies. Purther, the poultice in the latter stages of a superficial phleg¬ 
mon not only hastens the formation of pus in the inflammatory focus, 
but lessens irritation in the outlying parts by its sedative action, and 
so softens the tissues as to aid in the passage outwards and the discharge 
of the inflammatory products. When poulticing is too long persisted 
in, the part becomes pale or white, swollen, relaxed, and has a sodden 
look; the granulations of the ulcer or abscess are large, pale, and very 
flabby, and all the vital actions are below the normal point. It is pos¬ 
sible that even death of a part might be brought about by continuous 
poulticing. Be this as it may, after the discharge of pus, whenever 
the j)arts put on the aspect just spoken of, the poultice should be re¬ 
moved and stimulating applications be substituted. 

So far, the use of poultices to combat external inflammations has 
alone been spoken of; but clinical experience has demonstrated their 
value in internal inflammations, even when such deep-seated tissues as 
the lungs are affected. Their action in these cases is somewhat differ¬ 
ent from that which they exercise over superficial inflammations. Ac¬ 
cording to the dictates of experience, they should be applied very hot, 
and be frequently renewed; very often, too, a small amount of mustard 


EMOLLIENTS. 


833 


or of some similar stimulating material is added to them with advan¬ 
tage. As a result, these poultices act as gentle but deep-reaching 
counter-irritants, which in all likelihood affect not merely the blood¬ 
vessels of the skin, but also those of the subdermal tissue. When it 
is borne iu mind that in all these cases the poultice is applied to a very 
large surface, it will be readily perceived that this counter-irritation is 
a powerful one. Thus, in pleurisy , or in pneumonia , the whole anterior 
or posterior surface of the chest is covered, or perhaps the whole chest 
is enveloped, by the jacket-poultice. In peritonitis , the poultice should 
be as large as the abdomen of the patient. In either of these cases 
the amount of blood drawn to the surface must be considerable. I can¬ 
not help surmising that the water of the poultice in some cases actually 
soaks through and exerts its direct sedative influence upon the affected 
tissue. The value of poultices in lung-diseases has seemed to me much 
greater in children, whose chest-walls are very thin, than in adults; and 
it is not illogical to believe that the difference may be dependent upon 
the inequality of the chest-walls. 

The jacket-poultice should be made of thin flannel formed into a 
sort of double bag, so cut and shaped as to fit the individual, and se¬ 
cured in front with safety-pins and over the shoulders with tapes, or it 
may be fastened directly to an undershirt, a piece of oiled silk always 
being placed directly outside of the jacket. The jacket should be 
divided into two parts by a horizontal line of stitching, and be filled 
from one end. In order to prevent sagging of the contents, it is well, 
after filling, to take a stitch here and there, in the manner of quilting. 
The effect of a jacket-poultice may be imperfectly attained by cover¬ 
ing the patient with wool batting and oiled silk outside of this,—in 
fever patients the moisture from the surface and the heat of the body 
serving to form a kind of fomentation. 

Flaxseed meal is the most frequently used substance for making 
poultices, for which purpose the large amounts of oil and mucilage 
which it contains especially fit it. Ground slippery elm makes a very 
elegant demulcent, mucilaginous poultice. Ordinary mush from Indian 
meal affords a cheap and very serviceable material, and bread and milk 
makes a popular, very mild and unirritating, but expensive poul¬ 
tice. When a poultice is to be applied to affect internal organs, and 
consequently has to be large and capable of holding the heat for a 
long time, the choice of material lies exclusively between flaxseed and 
Indian meal. The former of these is the more adhesive and makes 
the more manageable poultice; but popular belief, and I think with 
reason, attributes to mush a superior power of retaining heat. In 
either case the poultice should be put on as hot as it can be borne, and 
should be covered by a large piece of silk oil-cloth, which aids in re¬ 
taining not only the moisture, but also the heat. The interval of re¬ 
newal should be short, and should be governed solely by the rapidity 
with which the applied poultice grows cold. 

53 


FAMILY XYL—DILUENTS. 


A diluent is an indifferent substance which is absorbed and in 
its passage through the body simply dilutes the various fluids of the 
organism, as well as the excretions. The only diluent is water, which 
is given in various forms. Thus, the natural medicinal waters owe 
much of their value to the large quantity of water they contain. It 
is evident that when a quart of water more than usual is taken into 
the system, it must while it stays there lessen the concentration of the 
bodily liquids, and must finally in some way find an exit from the body. 
The increased excretion even of water means increased action in the 
eliminating glands ; and the water passing out of the blood must always 
carry with it more or less of the soluble matters contained in the same, 
so that while the percentage of solid matter in the urine or in the sweat 
may be lessened by large potations of water, the actual amount elimi¬ 
nated is no doubt increased. Hence water acts not only as a diluent, 
but also as a depurant. 

It is especially in regard to the urinary organs that water is em¬ 
ployed medicinally, with three distinct possible objects. Thus, it may 
be used simply to aid the re-establishment of completely or partially 
suppressed renal secretion. In acute Bright's disease water has been 
found to be an efficient diuretic, increasing very remarkably the urinary 
excretion, relieving the irritation of the kidneys, and aiding the return 
to health. In these cases at least half a pint of water should be taken 
every two hours. I have tried it in chronic Bright’s disease, and found 
it to work well in some cases; but in others, no increase of the urine 
taking place, the water accumulated in the system and added to the dis¬ 
tress. Again, dilution of the urine is often important, as in gonorrhoea , 
or when there is a tendency to the formation of either gravel or calculi. 
Water is also used as a depurant in chronic disorders in which there is 
no organic disease, but an habitual torpor of the emunctories,—cases 
in which the liver is said to be torpid, and in which there is a foul 
tongue, habitual costiveness, and a scanty urine with a tendency to 
the formation of a lateritious deposit.* In these cases a couple of 
tumblerfuls of water upon rising will often produce a stool after break¬ 
fast, as well as increase the flow of urine. Very generally a mild saline 
may be advantageously added in small quantity to the water; and such 
natural mineral waters as those of Saratoga are especially beneficial. 

* For experimental evidence that water in rabbits does increase the flow of bile, see 
Zawilski, Centralbl. fur Chir., 1877, p. 327. 

834 




FAMILY XVII— PEOTEOTIYES. 


In the present class are included those materials used by the physi- 
cian as external applications to exclude the air and to protect inflamed 
dermal or other tissues. Sufficient has already been said in regard to the 
importance of the exclusion of the air, under the heading of Emollients. 
It is evident that the latter class of remedies, as well as demulcents, 
act as protectives; but the class of Protectives proper seems necessary 
for the consideration of certain remedies which act more plainly in a 
mechanical method in defending the skin against external agencies. 

First to be considered under the present class are certain plasters, 
used to protect the skin and raw surfaces from external influences. 
The adhesive plaster (Emplastrum Resince, U.S.) is used enormously for 
mechanical purposes. It does, however, irritate the skin somewhat, 
and consequently is rarely employed where protection is the only 
object. Under the latter circumstances, the lead plaster (Emplastrum 
Plumbi , U.S.) or the soap plaster (Emplastrum Saponis , U.S.) is prefera¬ 
ble. These substances are free from irritant properties, but are very 
slightly adhesive, and are scarcely used except to protect the skin from 
pressure or friction, as when bed-sores are threatened. They should be 
spread upon very soft kid. It is also very important that they be not 
so thick or hard as to lose their pliability. If they are stiff, by their 
movements during the motions of the body they may do much harm. 

COLLODIUM—COLLODION. U.S. 

When any finely-divided ligneous body, like raw cotton, is steeped 
for a few minutes in a mixture of nitric acid of the specific gravity of 
1.5 and concentrated sulphuric acid, and then squeezed, thoroughly 
washed, and dried, it gains about seventy per cent, in weight, and is 
converted into pyroxylin, or gun-cotton. The change consists in the 
substitution of nitryl (N0 2 ) for a portion of the hydrogen. There are 
a number of varieties of gun-cotton. The true explosive gun-cotton, 
alone adapted for gunnery, is trinitrocellulose. It is not so soluble as 
the less highly nitrated variety, and is not fit for use in medicine. The 
officinal pyroxylin ( Pyroxylinum , U.S.) is one of the more soluble varie¬ 
ties of gun-cotton, but is not soluble to any extent in ether. 

Gun-cotton is a perfectly inert substance, so far as the external 
surface of the skin is concerned, and probably has no effect upon the 
system when taken internally. It is not at all soluble in water, and its 
only use in medicine is in the manufacture of collodion. This substance 

835 



836 


LOCAL REMEDIES. 


is officinally prepared by dissolving two hundred grains of pyroxylin 
in a mixture of twelve and a half fluidounces of stronger ether and 
three and a half fluidounces of stronger alcohol. It is a colorless, 
slightly opalescent liquid, of a syrupy consistence, and smelling strongly 
of ether. By long standing it deposits a layer of fibrous matter, and 
becomes more transparent. This layer should be reincorporated, by 
agitation, before the collodion is used. When it is applied to the skin, 
and the menstrua are allowed to evaporate, collodion forms a colorless, 
transparent, flexible, and strongly contractile film, which adheres very 
closely, and cannot be readily removed by washing, motion of the part, 
or external mechanical force. As this coating is perfectly impervious 
to air and water, collodion is much used in surgery for various purposes. 
It is evident that care should be used in its application to abscesses 
and discharging wounds, lest it should prevent the discharge of pus. 
Small fresh wounds are often very advantageously dressed in the fol¬ 
lowing manner, especially cuts on the fingers and about the head. If 
necessary, the hair should first be shaved off the part, and then a piece 
of coarse gauze or mosquito-netting, of suitable size and shape, should 
be laid so as to cover the wound and extend across each side from half 
an inch to an inch and a half, according to circumstances. One end 
should then be tightly fastened to the skin by repeated applications 
of the collodion with a camel’s-hair brush. When the adhesion has 
become sufficiently firm, the gauze should be drawn so as to close the 
wound tightly, and while it is held in position the collodion should be 
applied all over it. As the collodion contracts during drying, the wound 
is more and more tightly closed and bound together. 

The contraction of the collodion film is a great drawback to its use 
for certain purposes. This can be in great measure obviated and the 
film made more pliable by the addition of from eight to ten drops of 
castor oil to the ounce of the liquid. Under the name of Flexible Col¬ 
lodion (Collodium Flexile ), the U.S. Pharmacopoeia directs a preparation 
very similar to that just spoken of. It contains twenty grains of Canada 
turpentine, besides ten grains of castor oil, to the ounce; and probably 
the stimulant effect of the terebinthinate will make itself apparent 
upon some susceptible skins. Whenever collodion is used simply as a 
protective, one of these modified preparations is much preferable to the 
pure article. Any principle which is soluble in a mixture of ether and 
alcohol may be added to collodion, and in this way medicinal substances 
may be applied to the external surfaces. The films formed are often 
less firm and adhesive than those of the simple collodion. 

Solution of Gutta-Percha (Liquor Gutta-Perchce , U.S.) is made by dis¬ 
solving small pieces of gutta-percha in chloroform. When it is applied 
to the skin, a thin elastic adhesive film is left, which protects the parts 
from the air. It is a very elegant preparation for use in small cuts, 
abrasions, chapped lips, and the little injuries which come within the 
province of domestic medicine rather than that of the professional art. 


DIVISION II—EXTRANEOUS REMEDIES. 


These are drugs which are employed not to act directly upon the 
human system or upon any of its tissues, but upon some extraneous 
material or entity, either in the cavities of the body or upon its exterior. 
Thus, an antacid neutralizes acid in the stomach, or an anthelmintic 
kills the tapeworm in the intestines, or a disinfectant destroys poisonous 
emanations in the exterior world and thereby wards off disease. 


FAMILY I—ANT ACID S. 

Antacids are, strictly speaking, substances which are capable of 
neutralizing acid. The class, as here defined, contains those remedies 
which in medicine are used for the purpose of neutralizing an excess 
of acidity in the primse vise. They are almost solely employed in forms 
of dyspepsia. Without doubt, cardialgia, gastric uneasiness , “ heartburn ,” 
and the rising of sour water in the mouth, are often the result of too 
much acid in the stomach, perhaps secreted by a perverted glandular 
action, but more probably in the great majority of cases formed by fer¬ 
mentative changes in the partially-digested food. As excessive acidity 
of the stomach causes gastric uneasiness and derangement, so will a 
similar condition of the intestinal canal cause pain and spasm and 
functional disturbance in the bowels. This is seen most frequently in 
infants, and is very often associated with a diarrhoea in which the pas¬ 
sages have a green color, similar to that of spinach, and hence are 
sometimes spoken of as “ spinach-stools.” In diarrhoea of this character, 
as well as in colic , antacids are often of service by neutralizing the acid 
in the intestinal canal. 

Clinical experience has demonstrated that dyspepsia is often perma¬ 
nently relieved by the use of alkalies when they are given steadily day 
after day, about twenty minutes after eating, for a long time. Accord¬ 
ing to Dr. Thomas K. Chambers ( The Indigestions , Am. ed., 1870, p. 67), 
this is dependent upon an effect pointed out by Claude Bernard, the 
augmentation of the acid gastric juice, and so of the normal peptic 
powers of the stomach. The same authority further says, “The test 
of benefit being derived from an alkali is the dose not requiring to be 

837 




838 


EXTRA XEO US REMEDIES. 


increased as the patient goes on taking it, but, on the contrary, being 
diminished gradually, while relief from the recurrence of heartburn 
continues still to be experienced.” 

Sick headache is sometimes dependent upon gastric irritation pro¬ 
duced by an excess of acid in the stomach. This true sick headache 
is generally to be distinguished from migraine by the early occurrence 
of the stomach-symptoms, either as heartburn, nausea, vomiting, or 
simple gastric distress, and by the fact that the pain comes on with an 
attack of blindness or of dizziness, and is not limited to any one spot, 
as the supraorbital or other neuralgic foci, but is felt all across the 
brows. In this form of cephalalgia antacids often afford relief. 

Yarious substances which have already been discussed in this work 
are excellent antacids, most of them uniting this to other medicinal 
properties. Thus, when a stimulating antacid is desired, as is very often 
the case in sick headache, half a drachm of the aromatic spirit of harts¬ 
horn may be taken, well diluted with water. Again, when a laxative 
antacid is desired, a teaspoonful to a tablespoonful of magnesia may be 
exhibited. Potassa and its carbonates have already been dwelt upon 
with sufficient detail. They may be used as antacids; but, as they 
exert other powerful influences upon the system, they are, I think, not 
so generally useful as the soda preparations. JSTevertheless, the Solution 
of Potassa (Liquor Potassce, U.S.) is largely employed as an antacid. 
It is a colorless, water-like liquid, of a strong, acrid, alkaline taste, and 
is made by boiling a solution of the bicarbonate of potassium with 
lime. It contains only five and eight-tenths per cent, of the alkali, but 
acts upon animal and vegetable substances, and imparts a distinct soapy 
feel to the fingers when they are moistened with it and rubbed upon 
one another. It is capable, in overdose, of acting as an irritant poison. 
The dose is ten to twenty minims, well diluted. 

SODIUM. 

Unlike potassium, sodium and its salts have very little influence 
upon the higher animals. Frogs are much more affected, it causing 
spinal convulsions, and slowing, or even diastolic arrest, of the heart 
(Podocaepow, Virchow's Archiv, xxxiii. 507; Schdnlein, Arch. f. d. Ges. 
Physiol ., xviii. 26). M. Laffout affirms that sodium primarily stimulates 
the frog’s heart ( Compt.-Rend. Soc. Biolog., 1880, p. 282). Professor S. 
Ringer and Dr. H. Sainsbury find that the sodium salts are capable of 
arresting the cut-out frog’s heart in diastole, the arrest being preceded 
by very little disturbance of rhythm: the amounts required were, how¬ 
ever, so large that sodium salts can hardly be made to kill ( London 
Lancet, 1882, ii. 736). 

On the other hand, Grandeau (Robin’s Journal de VAnatomie, 1864) 
found that one hundred and seven grains of the carbonate of sodium 
injected into the vein of a dog produced only very slight symptoms, 
and that thirty-five grains of the nitrate similarly administered to a 


ANTACIDS. 


839 


rabbit caused only some convulsive movements. According to Gutt- 
mann ( Virchow's Archiv, Bd. xxxv.), however, the sodium salts thrown 
directly into the blood in very large amounts will slowly cause death, 
the agony being very prolonged, and, when the chloride is used, con¬ 
vulsions being developed. Both Podocaepow and Guttmann assert that 
even the largest doses do not sensibly affect the heart or the tempera¬ 
ture ; and the latter observer further declares that they are without 
influence upon the nerve-centres, the peripheral nerves, or the muscles. 
If this be the case, however, it is difficult to perceive how they can 
cause death; and the earlier experiments of Podocaepow indicate that 
they do exert a very feeble action upon the peripheral nerves or the 
muscles. 

Upon the blood* the immediate influence of the sodium salts is very 
slight, for Podocaepow asserts that one part dissolved in twelve parts 
of blood does not affect either the physical characters of the red cor¬ 
puscles or the intensity of the ozone reaction; whilst Dr. H. G. Beyer, 
as the result of experiments made upon terrapins, comes to the conclu¬ 
sion that sodium salts excite first the ganglia of the vaso-dilator nerves, 
and afterwards those of the vaso-motor nerves [Med. News, Sept. 4, 
1886); and Dr. T. W. Mills ( Canada Med. and Surg. Journ., March, 
1886) finds that the carbonate of sodium has a distinct effect in stimu¬ 
lating the heart of the fish. Curci ( Lond. Med. Record , Oct. 15, 1886) 
also finds that the sodium salts increase the blood-pressure after the 
destruction of the oblongata, and believes that they influence the 
peripheral vaso-motor nerves. Professor S. Ringer ( Brit. Med. Journ., 
April, 1885) states that while the lime salts, added to distilled water 
circulating through the isolated frog’s heart, stimulate and prolong the 
ventricular contractions, the sodium salts fail to have this effect, also 
that in the frog the sodium salts have a very distinct influence upon 
the muscles (Ibid., July 19, 1884). 

The effect of the continuous exhibition for a few days of large 
amounts of salt upon the human organism has been elaborately inves¬ 
tigated by Dr. Munch (Archiv Vereins Gemeinschaft Arbeiten, Bd. vi. p. 
369,1863), and found to be very feeble. At first there was a slight dimi¬ 
nution of excretion, and a corresponding gain of the body in weight; 
but after a time the excretions increased, and the weight of the body 
decreased. The variations in excretion affected chiefly the urine, but 
sometimes the perspiration and faeces were also influenced. The urine 
was rendered alkaline, but its solid ingredients were scarcely at all 
affected. 

Although a certain amount of the sodium salts is a necessary food for 

O 


% Professor Kowalewsky records in the Centralbl. f. yied. Wissen., 188i, the results of an 
elaborate study of the effects of adding, either in solid form or in concentrated solution, salts 
of potassium, sodium, lithium, and ammonium to the blood. As it is not possible at present 
to connect this influence with the effects of therapeutic doses of the drug inside of the body, I 
content myself with referring to the paper. 



840 


EXTRANEOUS REMEDIES. 


the higher animals, yet it is very doubtful whether an habitual excess 
of them has any decided effect upon nutrition. MM. Damourette and 
Hyades claim that the elimination of urea and uric acid ( Journ. de 
Therap., 1880, 440) is markedly increased; but an examination of their 
experiments will show that this conclusion is not warranted by them, 
and in a series of experiments with the phosphate, acetate, and sul¬ 
phate of sodium, Dr. I. Mayer ( Zeitschr. f. Klin. Med., 1881, 82-95) 
found no increase, and the experiments of A. Ott on the dog gave the 
same results (Hoffmann u. Schwalbe's Jahresbericht, 1883. 220). Plouriez 
( Compt.-Rend ., t. xxv.) believes that the chloride has a tonic influence: 
he analyzed his blood after he had used daily one hundred and fifty 
grains of salt beyond the ordinary amount for three months, and again 
after he had taken only the usual quantity. The red corpuscles were 
very decidedly more numerous, the fibrin was slightly more abundant, 
and the albumen decidedly less abundant, at the first analysis than at 
the second. 

As Bidder and Schmidt ( Canstatt's Jahresbericht , 1852) assert that 
the hydrochloric acid of the gastric juice is derived from chloride of 
sodium, and as Babuteau (X’ Union Med., t. xii. p. 186, 1871) found that 
in dogs with gastric fistula both the quantity and the acidity of the 
gastric juice are decidedly increased by the use of salt meat, it would 
appear probable that common salt acts as a tonic by increasing the 
digestive power. On the other hand, it is well known that physiolo¬ 
gists are still disputing as to whether free hydrochloric acid exists 
at all in the gastric juice.* Further, it is certain that pepper or any 
similar condiment will, by its local action, increase the flow of gastric 
juice; and in Rabuteau’s experiments the mere local irritation of the 
salt, or the difficult digestion of the preserved meat, may have given 
rise to the increased secretion by the stomach. 

The experiments of Dr. S. W. Lewaschen prove that the carbonate, 
the sulphate, or the phosphate, given to dogs with biliary fistula, in¬ 
creases very markedly the liquidity of the bile by diminishing the per¬ 
centage of solids. The salicylate of sodium acted similarly to but much 
more powerfully than these salts. These experiments are in accord 
with clinical experience, which shows that the alkaline salts of sodium 
given one to two hours after meals in full doses are of decided value 
in the treatment of gall-stones and various affections associated with 
excessive viscidity of the biliary secretion. 

Soda, TJ.S. — Caustic Soda is prepared by the evaporation of the 
liquor, and occurs in grayish-white fragments, which deliquesce when 
exposed to the air; but, as the fluid absorbs carbonic acid and the soda 


* See Bernard’s Physiologic Experimentale, t. ii. p. 393, also Phila. Med. Times, vol. v., 
and, for a discussion of the subject, Professor F. G. Smith’s note to the American edition of 
Marshall’s Physiology, p. 530; also Longet’s Physiologie, Paris, 1861, t. i. p. 196. 



ANTACIDS. 


841 


in it is converted into an efflorescent carbonate, the liquid is after a 
time converted into a white powder. Caustic soda is powerfully cor¬ 
rosive. Liquor Sodce , U.S.— Solution of Soda. —A colorless, exceedingly 
acrid liquid, containing about five per cent, of hydrate of sodium, and 
having the specific gravity 1.059. It is made by the action of milk of 
lime upon a solution of carbonate of sodium. 

Sodii Carbonas, U.S.— Carbonate of Sodium occurs in colorless crys¬ 
tals, which rapidly effloresce on exposure to the air, and fall into a 
white powder. The taste and reaction are strongly alkaline. It is 
very soluble in water, insoluble in the air. The chief native mate¬ 
rials from which it is manufactured are common salt and sulphate 
of sodium. As it occurs in commerce, carbonate of sodium is suffi¬ 
ciently pure for ordinary use. When carbonate of sodium is heated, 
its water of crystallization is driven off, and the officinal Dried Car¬ 
bonate (Sodii Carbonas Exsiccatus , U.S.) is left. This may be given in 
pill-form. Commercial Bicarbonate of Sodium ( Sodii Bicarbonas Venalis, 
U.S.) is a white, opaque powder, containing variable amounts of soda 
not fully saturated with carbonic acid. Pure Bicarbonate of Sodium 
(Sodii Bicarbonas , U.S.) should always be selected for internal use. 
The antacid dose of these preparations is ten to twenty grains. 

Therapeutics.— The fact that soda, in moderate amount, has no 
depressing action, and indeed very little, if any, influence upon the 
general system, renders it preferable to potash in cases of acidity of 
the primse vise. It is par excellence the alkali for acid dyspepsia. On 
the other hand, the circumstance clearly established by Dr. Roberts 
( Urinary and Renal Diseases , Amer. ed., 1866, p. 240), that it is less 
powerful as a solvent of uric acid than its sister alkali, together with 
the property, believed to belong in a much greater degree to potash, 
of preventing the formation of uric acid, makes soda of very inferior 
value in uric acid gravel or uric acid diathesis. When in any case it is 
desirable simply to render the urine alkaline, and at the same time 
to avoid depressing the system generally, soda would, on theoretical 
grounds at least, seem preferable. 

Sodii Acetas , U.S.— Acetate of Sodium is a white, slowly efflorescent 
salt, which occurs in long prisms of a sharp, bitterish taste. It has 
been supposed to have the same remedial powers as acetate of potas¬ 
sium; but this is certainly a mistake. It is rarely if ever used in 
medicine. Nitrate of Sodium , although officinal, is not used as a thera¬ 
peutic agent. 

CALX—LIMB. 

The therapeutic properties of slaked lime are dependent chiefly upon 
its alkalinity and its astringency. It does not possess the latter prop¬ 
erty in an eminent degree, yet its preparations, when properly diluted, 
whiten and lessen the secretion of mucous membranes to which they 


842 


EXTRANEOUS REMEDIES. 


are applied. It also appears to have, as it were, a sedative influence 
upon mucous membranes, lessening their irritability. Caustic or un¬ 
slaked lime is a powerful caustic, but, except in the form of Vienna 
paste, is rarely if ever used as such. It is more soluble in cold than in 
hot water. At 60° F. it requires about seven hundred times its weight 
of the liquid to dissolve it. It is much more soluble in syrup than in 
pure water. 

Liquor Calcis, TJ.S. — Solution of Lime. — Lime-water is a colorless 
liquid, having the sp. gr. 1.0015, and containing about 0.15 per cent, of 
lime. It has an alkaline taste, and is nearly destitute of irritant prop¬ 
erties. On exposure to the air it becomes turbid, or forms a crust upon 
the surface, or deposits a precipitate, owing to the absorption of car¬ 
bonic acid from the air and the conversion of the lime into a carbonate. 
Twenty minims of syrup of lime (Syrupus Calcis , U.S.) equal a fluid- 
ounce of lime-water. 

Therapeutics.— Lime-water is used internally exclusively for its 
effects upon the primae visa. In vomiting , from almost any cause except 
acute gastritis, equal parts of lime-water and milk afford an elegant, 
simple, and much-used remedy. If the vomiting be severe, all other 
food should be inhibited, and one or two tablespoonfuls of the mixture 
given every half-hour,—the quantity, as well as the proportion of milk, 
being increased as the stomach is able to bear it. As lime-water when 
put in milk prevents the formation of dense coagula, it is often added 
with advantage to that fluid when used as food for infants, or for adults 
with weak digestion. As an alkaline astringent, the syrup is often 
useful in diarrhoea in doses of one to two fluidrachms well diluted. 

Externally, lime-water has been used as a wash in various skin-dis¬ 
eases, especially in tinea capitis: it is also applied to ulcers , and is said 
to have a very marked influence in lessening the amount of dischftrge. 
When mixed with an equal bulk of linseed or olive oil ( Linimentum 
Calcis , U.S.), lime-water is a favorite application for recent burns: the 
thick, soapy liquid which is fonned is sometimes spoken of as Carron 
Oil, from the name of the iron-works at which its reputation was 
first made. 

Lime-water has the power of dissolving mucus, and also false mem¬ 
brane, and has therefore been introduced as a local remedy in pseudo¬ 
membranous croup and in diphtheria. It is sometimes used by causing 
the patient to inhale the vapors of slaking lime; but a better method 
is to pulverize lime-water by means of an atomizer and direct the spray 
upon the back of the fauces while the patient is respiring deeply. The 
application should be made every two or three hours, and, in patients 
of sufficient age to allow of its being thorough, is often very service¬ 
able. 

Soluble preparations of lime are not devoid of influence upon the 
general tissues of the body, but it is not probable that they are suffi- 


ANTACIDS. 


843 


ciently active to cause any appreciable effect when given in therapeutic 
doses. Professor Ringer has found that the calcium salts have the 
power of increasing and prolonging muscular contractility when they 
are brought into contact with an isolated voluntary muscle or with the 
heart of the frog ( New York Med. Record , vol. xxxi.). Dr. H. G. Beyer 
{Med. News, Sept. 1886) states that the same salts cause contraction of 
the blood-vessels of the terrapin. 

% 

CARBONATE OF CALCIUM. 

Chalk is the native, friable carbonate of calcium, a milk-white, soft 
solid, of an insipid, earthy taste, insoluble in water, wholly soluble, 
with effervescence, in dilute muriatic acid. Creta Prceparata, U.S.— 
Prepared Chalk is chalk freed from impurities by pulverization, leviga- 
tion, and elutriation; a white, perfectly smooth powder. Calcii Car- 
bonas Prcecipitatus, U.S.— Precipitated Carbonate of Calcium is a white 
powder, free from grittiness, which is made by precipitating chloride 
of calcium with carbonate of sodium. 

Therapeutics. —Carbonate of calcium in its different forms is used 
internally as an antacid and a very mild astringent. As none of the 
salts which it forms are purgative, it, with the other preparations of 
lime, is the best antacid when diarrhoea is present. The crude chalk 
should never be used, but the other preparations are probably of equal 
value. Some practitioners claim, however, that the oyster-shell is more 
acceptable to delicate stomachs, on account of the animal matter which 
it contains; and, under the name of Castillon's Powder , a mixture of 
salep, tragacanth, sago, of each three parts, prepared oyster-shell one 
part, and cochineal sufficient to color it, has been much used in obsti¬ 
nate summer diarrhoeas. A drachm of this is boiled in a pint of milk, 
and the decoction taken as food ad-libitum. The dose of carbonate 
of calcium is twenty grains to a drachm. Chalk Mixture (Mistura 
Cretce, U.S.) is generally preferred to the powder. It contains thirty 
grains of the chalk to the ounce, and is given in doses of one to two 
tablespoonfuls. It is often combined with laudanum or paregoric and 
tincture of kino or catechu. 

Externally, prepared chalk and precipitated carbonate of oalcium 
are used as desiccants and protective applications to ulcers and chronic 
burns , also in excessive sweating of the feet, and in intertrigo and other 
affections of the skin. 


FAMILY H.—ANTHELMINTICS. 


These are medicines which kill or cause the expulsion of intestinal 
worms. They are sometimes divided into vermicides , those which kill, 
and vermifuges , those which expel; but there is little or no practical use 
in the division. It is of much greater importance to establish the re¬ 
lations between these drugs and the different species of entozoa, since 
clinical experience has demonstrated that an anthelmintic very efficient 
against one form of intestinal worm may be not injurious to another 
species. Therapeutically considered, the entozoa may be divided into 
the Tapeworms (Tcenice), the Round-worms (Lumbrici ), and the Seat-worms 
(Ascarides ). The last of these differ from the others in that they are 
to be attacked solely by enemata. 

It is obvious that the value of an anthelmintic depends not only 
upon its power of poisoning the articulate, but also upon its harmless¬ 
ness as regards the patient. Thus, it is the eminent combination of 
these qualities that renders the infusion of quassia so valuable in cases 
of seat-worms, while carbolic acid, though very efficient, should never 
be used against the same parasite, since it has greatly imperilled, if it 
has not destroyed, the life of the patient when so employed. 

There are certain general rules which govern the administration of 
anthelmintics, and which should not be lost sight of. They may be 
summed up as follows: Let the alimentary canal be as empty as possi¬ 
ble, so that the drug may act with the greatest force upon the enemy. 
For this reason, anthelmintics are best administered early in the morn¬ 
ing ; and in obstinate cases the patient should be required to fast until 
dinner-time. 

If the drug be not itself a purgative, from four to eight hours after 
its administration a brisk cathartic should be administered; or a purga¬ 
tive dose of calomel may be combined with it, as the bilious purging 
induced by the latter drug seems to be especially obnoxious to the 
entozoa. 

SPIGELIA—PINKROOT. U.S. 

The root of Spigelia Marilandica, an herbaceous perennial, growing 
in the Southern and Southwestern United States. It consists of a 
knotty head, with numerous fine, crooked, branching rootlets. The 
odor is faint and peculiar; the taste sweetish and slightly bitter. It 
contains, according to the analyses of M. Feneulle and of R. H. Stablen, 
tannic acid, fixed and volatile oils, resin, and a bitter uncrystallizable 
844 




A N THELMINTICS. 


845 


body; but exactly upon what its virtues depend has not been deter¬ 
mined. 

Physiological Action. —According to the investigation of Dr. H. 
A. Hare ( Medical News, March 12, 1887), spigelia produces in the frog 
exophthalmia, excessive muscular weakness, loss of reflex activity, and 
slowing of the heart, with at first increase of power of the systolic 
contractions but afterwards arrest in a condition of semi-diastole. In 
the dog the drug produces hurried respiratory movements, retching, 
wide dilatation of the pupil, internal strabismus, marked exophthalmia, 
muscular weakness and loss of co-ordination, and at last sleep, passing 
into coma and death from failure of respiration. The loss of muscular 
power and of reflex activity is spinal, both motor and sensory nerve- 
trunks escaping. Moderate doses produce in the warm-blooded animals 
slowing of the pulse, with fall of the arterial pressure. As the pulse is 
not affected after section of the vagi, the slowing is probably the result 
of central inhibitory stimulation. The fall of arterial pressure seems 
to be chiefly the result of an action upon the heart, since asphyxia 
causes at such times an immediate rise in the pressure,— ie., vaso-motor 
spasm. The observations of Drs. Hodge Thompson ( Inaug. Diss., 
quoted by Eberle), Eberle ( Materia Medica and Therapeutics , vol. i.), 
and Spalsburg ( Boston Med. and Surg. Journ., 1885) have shown that 
in overdose it causes in man acceleration of the pulse, dilatation of the 
pupils, heat and dryness of the skin, flushing and a swollen appearance 
of the face, with, in Eberle’s cases, talkative delirium. Two fatal cases* 
of poisoning by it are said to have been recorded. 

Therapeutics. —Spigelia is a most efficient remedy in cases of the 
round-worm, and is, when given within the bounds of moderation, 
entirely safe. It appears to narcotize the worm, and requires the use 
of a brisk cathartic. The fluid extract (Extractum Spigelice Fluidum , 
TJ.S.) is efficient in doses of two fluidrachms. A better preparation is 
the Fluid Extract of Spigelia and Senna (Extractum Spigelice et Sennce 
Fluidum , U.S. 1870), which is much liked by children on account of 
its agreeable taste. The dose for an adult is fgss; for a child two 
years old, f3ss to f 3i, repeated every four hours until it purges. 

Azedarach, U.S., the bark of the root of Melia Azedarach, or Pride 
of China, is used in the South as a remedy for the round-worm. It is 
said to possess poisonous properties similar to those of spigelia, yet it 
is affirmed that animals and children eat its fruit with impunity. It 
is usually given in decoction (3ii to Ojss, boiled to a pint), the dose 
being for a child a tablespoonful every two or three hours until the 
bowels are affected. 

Chenopodium, U.S., or Wormseed, is the fruit of Chenopodium 


* These cases appear to have been indefinitely copied, and are of doubtful authenticity. 




846 


EXTRANEOUS REMEDIES. 


anthelminticum, or Jerusalem Oak, a rank, odorous plant, growing 
about waste places in the suburbs of towns in the United States. It 
consists of minute, globular, light-brown seeds, about the size of a pin’s 
head, of a nauseous odor and a pungent taste, due to the volatile oil 
which they contain in large quantity. Wormseed Oil ( Oleum Chenopodii , 
U.S.) is of a light-yellow color, becoming darker and less fluid by age, 
of a peculiar powerful odor and a hot burning taste.* It has been 
used in hysteria , but is now employed ODly as an anthelmintic against 
the lumbricus, and more rarely the tapeworm. It is very efficient, and 
ten drops of it on sugar may be given to a child three years old, before 
breakfast, dinner, and supper, for two days, followed by a brisk purge. 

Brayera, U.S., or Koosso , is the dried flowers and unripe fruit of 
Brayera anthelmintica, a tree, native of Abyssinia. They occur in 
compressed greenish-yellow clusters, of a fragrant balsamic odor, and a 
taste which in a little while is acrid and disagreeable. Koosso contains 
a volatile oil, tannic acid, and a resin, Koossin or Tceniin , discovered 
by Pavesi. This is crystalline, white or yellowish, slightly soluble in 
water, freely so in alcohol, and was shown by Dr. Bedall ( Syd. Soc. 
Year-Book , 1868, p. 476) to be the active principle of the drug, which 
yields about three per cent, of it. Brayera is a most efficient remedy 
against the tapeworm, and even in large doses causes no greater incon¬ 
venience to the patient than some nausea, abdominal pain, and loose¬ 
ness of the bowels. It is generally not necessary to administer any 
purgative with it, and the worm is discharged dead with the last 
watery passages. A half-ounce of the powdered flowers is given sus¬ 
pended in water ( Infusum Brayerce —£ss f° Oss, U.S.) in the morning, 
with the usual precautions as to diet, or from twenty to forty grains of 
koossin, wrapped up in a wafer, may be substituted for the crude drug. 
The fluid extract (Fxtr actum Brayerce Fluidum , U.S.) is also efficient in 
doses of half a fluidounce. Care should be exercised in giving brayera 
to pregnant women, as it is stated that it has produced abortion. 

SANTONICA—SANTONICA. U.S. 

Levant Wormseed consists of the unexpanded flowers and pedun¬ 
cles of Artemisia Contra, a composite of Northern Middle Europe and 
Asia. It consists of pale, greenish-brown, smooth heads of four or five 
tubular flowers, of a very strong aromatic odor when rubbed, and a 
bitter, disagreeable taste. It contains volatile oil, resinous matter, and 


® In the Maryland Med. Journ., vol. iv. p. 20, Professor T. R. Brown reports a case in 
which death was attributed to the taking of an ounce or more of wormseed oil in divided 
doses. The patient was found in bed unconscious, with vomited matters over his surround¬ 
ings, after some hours became sensible, relapsed an hour or two later into heavy sleep, was 
again roused, and while playing cards became aphasic, deaf to conversation, acutely sensitive 
to other sounds, and finally died with hemiplegic apoplexy. It is plain that the wormseed 
was not the direct immediate cause of all these symptoms or of the fatal result. 



ANTHELMINTICS. 


847 


a crystalline principle, Santonin (Santoninum , U.S.), or Santoninic Acid , 
which occurs in colorless, pearly, four-sided, orthorhombic tables, soluble 
in from four thousand to five thousand parts of cold and two hundred 
and fifty parts of boiling water, freely soluble in alcohol and chloroform, 
moderately so in cold ether; insoluble, or nearly so, in glycerin. It 
has a neutral reaction, but unites with alkalies to form salts, and hence 
is freely soluble in alkaline solutions. When slowly heated, it sublimes, 
unchanged, at from 165° to 175° C. When rapidly heated, it is con¬ 
verted into a brownish-red oil, which becomes carmine-red upon the 
addition of caustic potash. On exposure to sunlight, or, more slowly, 
even in the ordinary daylight, the colorless crystals of santonin acquire 
a golden-yellow tint. If this change be a chemical and not a mechan¬ 
ical one, the alteration must be very slight, since, according to Krauss, 
the yellow crystals conduct themselves in their chemical relations pre¬ 
cisely as do the colorless crystals, and are precipitated, by the addition 
of acid to their alkaline solutions, as colorless crystals. 

Physiological Action. —Santonin is said to have been first intro¬ 
duced into medical practice in 1830, by Dr. Alms, by whom and by Dr. 
Kahler it was simultaneously discovered. It is at present used almost 
solely on account of its poisonous action upon entozoa, but certainly 
has a very great influence upon man and the higher animals. When 
it is given to dogs and rabbits in large doses it causes accelerated 
breathing, slowing of the pulse, universal trembling, cramps, free sali¬ 
vation, unconsciousness, convulsions, dilated pupils, and death. (See 
experiments of Manns, Das Santonin , Marburg, 1851, of Eose, Virchow's 
Archiv , Bd. xvi., 1859, and of T. Ivrauss, Inaug. Diss., Tubingen, 1869.) 
After death the lesions are not absolutely constant, but hyperaemia of 
the nerve-centres and congestion of the lungs and heart are nearly 
always present. According to Eose, dogs will recover after doses of 
from thirty to sixty grains, although five to six grains will produce 
very decided symptoms; and according to Krauss, thirty grains are 
required to kill a rabbit, even when the drug is dissolved in chloroform 
and given subcutaneously. 

The symptoms caused by large doses of santonin in man are closely 
similar to those which it produces in the lower animals. There are 
several fatal cases of poisoning by it on record. A child five years old 
was killed in half an hour by an unknown quantity {Pharm. Journ. and 
Trans., viii. 996), and one six or seven years old is said to have been 
destroyed by six grains of the acid, after suffering from hcematuria* 
( Bull. Therap., lxxiv. 362): four grains produced very serious symp¬ 
toms in a child four years old {Pharm. Journ. and Trans., ix. 696). In 
Dr. Grimm’s case {Schweizer Zeitschrift fur Med., Ghir. und Geburtsliilfe, 
1852, p. 493), a rather feeble child, five years old, took two one-grain 


* This is probably a mistaken observation, the urine being only blood-colored, and not 
containing blood (see p. 848). 





848 


EXTRANEOUS REMEDIES. 


doses of santonin, and was seized with convulsive tremblings, which 
increased in severity until they became severe convulsions, which were 
accompanied by unconsciousness, trismus, pallor of the face, cold sweats, 
dilated pupils, and rapid pulse and respiration. Thirteen or fourteen 
hours after the ingestion of the poison, while the patient lay on her 
back, quiet, unconscious, with moderately-dilated pupils and a slow, 
feeble pulse, death occurred suddenly. No post-mortem was allowed. 
The santonin is stated to have been chemically pure and to have been 
used in other cases with its usual results. Nine-tenths of a grain of 
santonin are said to have caused complete unconsciousness in a child 
five years old ( Schmidt's Jahrb., Bd. cci. p. 128). Six grains of santonin 
caused in a child five years old epileptiform convulsions and death in 
thirty-five minutes (Dr. W. J. Kilner, St. Thomas's Hospital Reports , 
vol. x.). One grain and a half produced in a child three and a half 
years old symptoms of the utmost severity, not reaching their maxi¬ 
mum until two days after the ingestion of the poison ( Therap. Gaz., 
iii. 210: for other cases, see Dr. C. Bevill, Therap. Gaz., iii. 428). In 
one case complete blindness persisted for nearly a week. Great pallor 
of surface, with a blue color around the eyes or involving the whole 
countenance, has been generally an early symptom; vomiting has not 
rarely been present, and sometimes has been accompanied by colicky 
pains. Besides these manifestations, giddiness, mental apathy or stupor, 
great coldness of the surface, profuse sweating, trembling, mydriasis, 
and finally loss of consciousness, with convulsions, often violent and 
accompanied by opisthotonos and emprosthotonos, and failure of respi¬ 
ration, are the usual phenomena of santonin-poisoning. The circula¬ 
tion seems to be very little affected (case, Arch, fur Exper. Path, und 
Pharm., vi. 302). 

A very curious symptom caused by santonin, even when in doses 
which can scarcely be called toxic, is xanthopsia, or “ yellow-seeing.” 
as the Germans term it. It was, I believe, first noticed by Calloud, 
and has since been spoken of by almost every writer upon the drug. 
Usually it consists of a very deep yellow tint imparted to the landscape 
and to every object looked at, an effect perhaps most comparable to that 
of looking through yellow glass; sometimes this yellow is replaced by 
green ; and Heydloff states that he has seen patients in whom the tint 
was red, and others in whom it was blue. Dr. Edm. Bose has published 
exceedingly elaborate papers upon this chromopsia; but, as the matter 
is of interest to the physicist and student of optics rather than to the 
clinician, I content myself with a reference to his memoirs ( Virchow's 
Archiv, xvi. 233; xviii. 15; xix. 522; xx. 245 ; xxviii. 30). Santonin 
is eliminated probably in a more or less altered condition by the kid¬ 
neys, and thus gives rise to a very characteristic symptom which has 
not as yet been spoken of,—namely, discoloration of the urine. The 
new color is a very marked yellow, which has at first an orange tint, 
but after very large doses becomes saffron-like, or sometimes even a 


A NTH EL MIN TICS. 


849 


purplish red, which has given origin to the idea that blood was present. 
According to Manns, the addition of an alkali to the yellow urine causes 
it to become red. The exact nature of the eliminated principle has not 
been determined: it is, however, probably the result of an oxidation of 
the santonin, as is believed by Kletzinsky, who asserts that the drug 
receives in the system six atoms of oxygen.* 

The results of the ingestion of large doses of santonin show that it 
has a very powerful action on the organism; but as to what portions 
of the latter are especially affected we have no information. Rose be¬ 
lieves that the chromopsia is due to a peculiar action of the drug upon 
the nerve-centres; but more probably it is simply the result of a very 
faint staining of the humors and other parts of the eye by the drug, 
and is analogous to the similar phenomenon sometimes seen in jaun¬ 
dice. Like very many other substances which escape through the 
kidneys, santonin increases the flow of urine, and, according to Dr. 
Farquharson (Brit. Med. Journ ., 1872), it increases slightly the elimi¬ 
nation of urea. 

Therapeutics. —Dr. D. Dyce Brown (Brit, and For. Med.-Chir. Bev., 
April, 1871), having noticed that a blind man to whom he was giving 
santonin for worms recovered to an extraordinary degree his vision, has 
recommended it in cases of loss of optic nerve power, and Dr. Ogston 
has used it with more or less complete success in a number of cases. 
Although Dr. Brown had apparently no knowledge of it, yet many 
years before his experience M. Guepin and M. Martin recommended 
the drug in amaurosis (Ann. de Therap ., 1862). M. Guepin believes it 
to be especially useful in amaurosis following choroiditis and iritis. 
Whether the use of santonin in diseases of the eye will ever amount 
to anything, cannot at present be told. The same may be said of its 
use in epilepsy (Brit. Med. Journ., 1876, ii. 787). 

As the result of experiments made with santonin in saline solution 
and also dissolved with oil, Yon Schroder (Arch. f. Exper. Path, und 
Pharm., xix. 304) affirms that it is very feebly toxic to the ascarides, 
and that it acts as a vermifuge simply by annoying the worm and 
causing it to loose its hold and allow itself to be swept out by purga¬ 
tives. This is, however, exceedingly doubtful. Santonin undergoes in 
the alimentary canal slow conversion into a soluble santoninate. Yon 
Schroder’s experiments, even if they be absolutely accurate, do not 
prove that the soluble santoninate of sodium slowly and persistently 
brought in contact with the worm does not destroy its life. The general 
opinion of helminthologists is that santonin is a parasiticide. Whatever 
its method of action may be, it is certainly very efficient against the- 


* Chrysophanic acid produces a discoloration of the urine similar to that caused by san¬ 
tonin. According to Hoppe-Seyler, the cause of the coloration can readily be distinguished 
by adding caustic soda to the urine, and then shaking up with amylio alcohol, when, if the 
coloration proceeds from santonin, the urine is decolorized, while, if it be due to chrysophanic 
acid, the alcohol takes up only traces of the coloring-matter. 

54 



850 


EXTRANEOUS REMEDIES. 


round or lumbricoid worm , but it should either be combined with or fol¬ 
lowed in about two or three hours by a brisk cathartic. The combina¬ 
tion of calomel and santonin has been much commended. 

Toxicology. —It has been denied that santonin is poisonous, and 
asserted that the evil results which have followed its use have been due 
to the mixture of strychnine with the drug. The only ground for this 
opinion is that in one or more cases death has resulted from strychnine 
being mixed with santonin, or else sold instead of santonin {Lancet, 
1877, ii. 857), through the carelessness of an apothecary. Dr. Walz, 
in an extended examination ( Jahresbericht fur Pract. Pharmacie, Bd. 
xv.), found that the santonin of the shops is pure; and it is inconceiva¬ 
ble how strychnine could be mixed with it except purposely or by the 
grossest carelessness. Moreover, the symptoms which have been pro¬ 
duced in alleged poisoning by santonin are very different from those 
caused by strychnine, and are in close accord with those which santonin 
induces in the lower animals. Finally, in some of the reported cases, 
seven of which are collected by Krauss, the santonin was examined and 
found to be pure. Under these circumstances, it would be absurd longer 
to deny the poisonous properties of santonin. The reason large doses 
have been so often given without serious results is probably the great 
hardness and insolubility of the crystals of the drug. The treatment 
of poisoning by santonin, after evacuation of the stomach and bowels, 
must at present be entirely tentative. One case appears to have been 
saved by artificial respiration (Arch, fur Exper. Path, und Pharm., vi. 
300) ; but Professor Binz (Ibid.') has found in animals nitrite of amyl, 
morphia, and artificial respiration alike useless: chloral given before 
the poison appeared to be of service. 

Administration.— Santonin is best administered in the form of 
lozenges, which, if the unbroken crystals are used, can be rendered very 
pleasant to the taste, so that children will eat them as candy. The dose 
of santonin for an adult is two to four grains; for a child two years 
old, one-fourtli to one-half grain. Very alarming symptoms have been 
caused by two one-grain doses exhibited within three hours in a child 
eight years old (Grimm); in a child two and a half years old, four 
grains apparently came very near causing death (Dr. Berg, Wurttem- 
berg. Medicin. Correspondenzblatt, 1862); and in the fatal case noted on 
page 845, only two grains were taken by a child five years old. For 
young infants, santonin is hardly a safe remedy in any efficient dose. 
AYhen a dose of any size is given, it should not be repeated in less than 
eight hours, and the last dose should be accompanied by a purgative 
amount of calomel. 

The santoninate of sodium (Sodii Santoninas, U.S.) has been proposed 
instead of santonin, but as an anthelmintic it is much more dangerous 
and less efficient: the object is to get as much of the remedy as pos¬ 
sible in contact with the worm, and, as to do this a slow, not a rapid, 
absorption is necessary, the insolubility of santonin is an advantage. 


ANTHELMINTICS. 


851 


Aspidium, U.S. — Filix Mas , or Male Fern, is the rhizome of Aspi- 
dium filix mas, or male fern of Europe. Under the name of Aspidium 
the present U.S. Pharmacopoeia recognizes it and the rhizome of the 
indigenous A. marginale. The rhizome, when perfect, is six to twelve 
inches long, and covered with large, brown, imbricated scales. Its taste 
is bitter and astringent. Its therapeutic properties appear to reside in 
an oleoresin (Oleoresina Aspidii , U.S.), which, as extracted by means of 
ether, is a dark, thick liquid, of a bitterish, nauseous, slightly acrid 
taste. Male fern is employed almost exclusively against the tapeworm. 
In its administration it is necessary to regard strictly the general rules 
applying with greater or less force to all the remedies of the class, 
which are especially imperative when a drug is employed against the 
tapeworm. The patient should live upon milk and a little bread for 
one day, and the following morning take a full dose (f3ss to f3i) of the 
oleoresin, fasting, and repeating it in two or three hours. At noon the 
patient may eat freely, and in the evening a brisk cathartic should be 
given. In overdoses male fern acts as a violent intestinal irritant: six 
drachms of the oleoresin have caused death in the adult {Lancet, Oct. 
14, 1882). 

Pepo, U.S.— Pumpkin Seeds. —The seeds of the ordinary pumpkin 
are a most valuable remedy in cases of tapeworm, perhaps even more 
efficient than the male fern, and perfectly harmless. Two ounces of 
the seeds may be beaten up with sugar into an electuary, or with water 
into an emulsion, and be taken fasting in the morning, the patient 
having dieted the previous day. Some hours after their administration, 
a brisk purge should be given. Mr. I. G. Wolff asserts that the active 
principle is a resin, which he has found efficient in doses of fifteen grains. 

Turpentine, in doses of half a fluidounce, has been used in cases 
both of tapeworm and of round-worm. It is efficient, but is liable to 
produce unpleasant effects, and should be employed only when other 
remedies have been used without success or are not to be had. It 
should be given in combination with twice its bulk of castor oil. 

Granatum, U.S.— Pomegranate Rind. —The bark of the pomegranate 
root is efficient, though very unpalatable, against the tapeworm. The 
decoction of the fresh root (gii to Oj) is to be preferred; a pint of it 
to be taken in three doses, an hour apart, before breakfast. The French 
chemist C. Tanret has isolated from the bark four alkaloids {Bull, de 
Therap., xcviii. 316), of which two, pelletierine and isopelletierine, have 
been found by Dujardin-Beaumetz to be active taeniacides. It is stated 
that in sufficient amount they act in the same manner upon the higher 
animals as does curare, causing paralysis of the motor nerves, without 
affecting sensation or muscular contractility {Ibid.). The dose of the 
salts of the alkaloids is said to be 4.6 grains. The efficiency of pelle- 


852 


EXTRANEOUS REMEDIES. 


tierine as an anthelmintic has been confirmed by various clinicians. It 
has by some been used in doses of twenty grains. Dujardin-Beaumetz 
also has employed it successfully in Meniere’s disease, and states that 
hypodermic injections of six grains produce in man severe vertigo and 
muscular weakness, with great retinal congestion. I have seen five 
grains cause in the adult pronounced muscular weakness amounting 
almost to general paralysis, and a number of cases have been reported 
in which it has produced in infants symptoms so severe as to discourage 
its employment in patients of that class. (See Bull, de Therap ., lxxviii., 
lxxix., lxxx., cxi., July, 1886.) M. Galezowski has used pelletierine in 
paralysis of the third and sixth pairs of nerves with asserted good 
results ( Brit. Med. Journ ., Nov. 28, 1885). 

Thymol has been used by Dr. Neuma Campi ( 11 Raccoglitore Medico , 
abstracted in Buffalo Med. Journ., Oct. 1886) for the destruction of tape¬ 
worm : he gives half an ounce of castor oil in the evening, in the 
morning two drachms of thymol divided into twelve doses, one to be 
taken every quarter of an hour, and twenty minutes after the last dose 
of thymol another dose of castor oil. It is also stated that Federici 
has found the remedy very effective against the Ancylostoma duodenale. 

Mucuna. — Cowhage. —The sharp, rigid hairs of the pods of Mucuna 
pruriens, an East India plant, were formerly used in cases of the round- 
worm. They are believed to kill the worm by piercing it. The pods 
are dipped into molasses, the hairs scraped off, and a tablespoonful of 
the thick mass given to an adult—a teaspoonful to a child—morning 
and evening, for three days, after which a brisk purge is administered. 

Kamala, U.S. — Kamala. —The hairs of the fruit of Rottlera tinc- 
toria, a plant cultivated in India as a dye-stuff. It is said to be an 
efficient parasiticide in cases of tapeworm. It is an orange-red, very 
inflammable, granular powder, mixing with water with some difficulty, 
and containing traces of a volatile oil and coloring resinoids, to one of 
which Dr. Anderson has given the name of Rottlerin. Kamala, in full 
doses, is actively purgative, indeed drastic, and sometimes causes also 
nausea and vomiting. It imparts its virtues to alcohol, and hence may 
be exhibited in the form of tincture. The dose of the powder is from 
one to two drachms suspended in syrup, given in the morning, and 
repeated in eight or ten hours if it do not purge. 


FAMILY III.-DIGESTANTS. 


In this family are associated a few remedies which are used to aid 
the alimentary canal in dissolving the various articles of food. 

PEPSINUM SACCHARATUM. U.S.—PEPSIN. 

As every one knows, there is secreted by the gastric glands a pecu¬ 
liar albuminous body, which has the power not only of coagulating 
albumen, but also, with the aid of acidulated water, of redissolving it. 
To this principle the name of pepsin has long been given. A discus¬ 
sion of its nature and properties would be more in place in a work 
on physiology than in one on therapeutics. 

The dried stomach of calves has been used since time immemorial 
for the purpose of coagulating milk, by housewives, with whom it is 
customary to place the dried viscus in wine, and to call the liquid thus 
formed, as well as the prepared stomach, rennet. It is stated by Dr. 
James Gray (j Edinb. Med . Journ., Jan. 1853) that rennet-wine should 
be of such strength that one teaspoonful of it will coagulate a pint of 
milk. Rennet is said to have been long used in England as a domestic 
remedy in dyspepsia ( Med . Times and Gaz., April, 1857). In South 
America the inner coat of the gizzard of the ostrich is stated to be 
put to a similar use (E. S. Wayne, American Journal of Pharmacy , 1868); 
and in our own country the dried gizzards of chickens and turkeys are 
no less famous among medically-inclined housewives. 

Dr. Corvisart, of Paris, is asserted to have been the first to propose 
the use of the active principle of the stomach in feeble digestion; and 
of latter years the manufacture and consumption of pepsin have become 
very great. Various processes have been suggested for the preparation 
of the drug, but none of them yield a pure proximate principle, if 
indeed pepsin have really such nature and be not an albuminous body 
of varying constitution. By most of the methods of manufacture the 
pepsin is obtained in the form of a viscid fluid ; and to change this into 
a powder requires the addition of starch or sugar, so that the powdered 
pepsin, as sold, contains a considerable percentage of foreign material. 

Whatever form of pepsin be used, if good effects are to be obtained 
from it it must be given with acid, unless indeed there be reason to be¬ 
lieve that this constituent of the gastric juice is not wanting. Alcohol 
destroys the digesting power of pepsin, and therefore wines are inferior 
preparations of it. The reactions of pepsin with organic and inorganic 



854 


EXTRANEOUS REMEDIES. 


matters are very complex, and not well understood: consequently 1 
think the physician should eschew all elixirs or compound preparations 
of the drug, using only the powdered pepsin or a glycerole of pepsin, 
or a freshly-prepared digestive solution of water and muriatic acid, or 
glycerin, water, and muriatic acid. If other remedies are to be given, 
it is no great hardship to write a second prescription for them. 

Therapeutics. —It is a question of some importance to decide how 
far pepsin is valuable and reliable as a medicine. It is evident that 
any influence for good which it possesses is dependent upon its solvent 
power, and that this, therefore, is a measure of its value. According 
to the experiments of Dr. C. L. Dana, which seem to be very reliable, 
good pepsin ought to dissolve in the stomach twenty times its weight 
of albumen; and the U.S. Pharmacopoeia requires that the pepsin, aided 
by hydrochloric acid, should dissolve fifty times its weight of coagu¬ 
lated egg albumen in five or six hours; but it is very doubtful whether 
twenty per cent, of commercial pepsin will do this. One of two con¬ 
clusions seems to be inevitable: either the doses of pepsin habitually 
used are preposterously small, or else pepsin acts upon the stomach 
itself in some way as a stimulant. Clinically, pepsin has been used 
with asserted advantage in the loss of digestive power in adults, whether 
primary or occurring in the course of other affections. Probably four- 
fifths of the drug which has been given has been inert, either originally 
or from the method of its administration; and in the great majority 
of cases the good that has been achieved has been probably due, not to 
the pepsin, but to the regulation of the diet and habits of the patient 
and to the drugs which have been exhibited along with the animal 
ferment. Its value has been overestimated, and it has been given to 
adults in ridiculously small doses: at least half a drachm of the com¬ 
mercial article should be given at a dose. The testimony as to the 
value of pepsin in diseases of young children is very strong. To such 
it is generally given in doses nearly as large as those usually exhibited 
in the cases of adults. If we represent the absolute digesting power 
of ten grains of pepsin as x, it is evident that x represents a propor¬ 
tionately much greater power in the primse vise of a child than in those 
of an adult. The use of pepsin in children is therefore much more 
rational than in adults; and my own experience is in close accord with 
what seem to me the dictates of common sense: in the chronic indiges¬ 
tion and consequent diarrhoea of young children it may be tried with 
great hope of benefit. To a baby six months old five grains may be 
given in a little acidulated water after each feeding. 

Pancreatin has been extensively used in dyspepsia as a digestant 
in lieu of pepsin. Its value is, however, problematical. For action it 
requires the presence of an alkali, and in the acid gastric juice would 
not only not act, but would itself in all probability be digested and 
destroyed as a ferment {New York Medical Record , xl. 398). Dr. J. 


DIGESTANTS. 


855 


Milner Fothergill proposes to prevent this destruction of pancreatin by 
administering ten to fifteen grains of bicarbonate of sodium with the 
dose; but it is not probable that this amount of alkali would sufficiently 
alter the gastric juice to allow of the escape of the pancreatin. 

EXTRACTUM MALTI. U.S. 

Malt is the seeds of the ordinary barley caused to enter the in¬ 
cipient stage of germination by artificial means and dried. It is pre¬ 
pared by soaking the grains in water, placing them in heaps in a room 
of moderate temperature, and by occasional turning preventing the beat 
given off during the process of germination from accumulating, and 
finally killing the germ by heat. The color varies from pale amber to 
black, according to the degree of the heat used in drying. There is 
formed during germination a peculiar ferment, diastase , one part of 
which is able to convert about two thousand parts of starch into dex¬ 
trin and glucose. The Extractum Malti of the U.S. Pharmacopoeia is 
made by rapidly evaporating an infusion of malt to the consistency 
of a thick, honey-like liquid at a temperature not above 130° F. It 
should contain practically all the diastase of the malt. The odor of 
the extract of malt is slight and peculiar, the taste sweet, and the re¬ 
action to paper distinctly acid. It dissolves freely in water, is precipi¬ 
tated by alcohol, tannic acid, mercuric chloride, and various other 
metallic salts. Commercial malt extracts vary greatly: some of them 
are practically preparations of glucose, others are of the nature of 
strong or weak beers. True extract of malt contains no alcohol at 
all. Extract of malt has been largely used in cases of disease with 
failing nutrition, and especially when the power of digesting sub¬ 
stances is feeble. When it contains largely either glucose or alcohol 
it affords food-material to the system; but the important question for 
the therapeutist is, How far is it possible in disease to aid in the 
digestion of starchy substances in the stomach and intestines by the 
use of diastase? R. H. Chittenden and G-. W. Cummins have made 
a series of investigations in order to determine the conditions which 
are necessary for the amylolytic action of diastase. They find that it 
acts better in a neutral than in an alkaline solution; that proteid mat¬ 
ters when present in the alkaline solution prevent the retarding influ¬ 
ence of an alkaline carbonate; that neutral peptone exerts a direct 
stimulant effect on the amylolytic action, but that its greatest amylolytic 
action is observed in the presence of proteid matter partially saturated 
with acid, although a larger percentage of acid-proteids may cause com¬ 
plete destruction of the ferment. These results seem to prove that 
diastase, when taken into the stomach, must sooner or later be com¬ 
pletely destroyed by the gastric juice, and that in order for it to have 
any distinct effect upon digestion it must be given at the beginning of 
the meal. In cancer of the stomach and other diseases in which the 
gastric juices lack acidity, the action of diastase upon starch must be 


856 


EXTRANEOUS REMEDIES. 


more pronounced; but unfortunately the failure of the starch-digestion 
is usually associated with gastric hyperacidity. 

PAPAIN. 

The Carica Papaya is an herbaceous tree universally cultivated in 
tropical countries for its fruit, the papaw, the juice of which yields a 
peculiar ferment, to which the name of Papain was given by M. Wurtz, 
but which is now generally known by the name originated by Pekolt, 
Papayotin. This substance is a ferment, which has the power of dis¬ 
solving fibrin, muscular fibres, tissues, etc. According to M. Wurtz, 
one part of Papain in alkaline solution at a temperature of 40° C. is 
capable of dissolving one hundred and seventy-five parts of moist fibrin, 
which it converts into a peptone. M. Wurtz affirms that it makes no 
difference whether the solvent solution be alkaline or acid, but Brunton, 
Wyatt, and Martin state that as little as one-half per cent, of hydro¬ 
chloric acid arrests the digestion. Albrecht, however, reaffirms that 
hydrochloric acid hastens the action of papain, and states that the 
officinal preparation in use in the Paris hospitals is an acid one. It is 
further stated that in order to convert fibrin entirely into pure peptone, 
so that nitric acid will produce no precipitate, the proportion of the 
ferment must be at least three per cent., and the digestion must con¬ 
tinue for forty-eight hours. Papain first coagulates milk, then precipi¬ 
tates it, and finally digests it into a thin fluid. Taken into the stomach, 
papain has no action upon the living tissues, but one grain of it injected 
directly into the blood is sufficient to cause death in a very short time 
in rabbits or in dogs. Its action on albuminoids is said to resemble 
that of trypsin rather than that of pepsin. (See Martin, Brit. Med. 
Journ ., July 25, 1885.) As it appears in commerce, papain is a grayish, 
very fine powder, which in its odor and taste strongly suggests pepsin. 

Therapeutics. —Papain has been used in medicine as a substitute 
for pepsin in the treatment of dyspepsia and gastric catarrh , in doses of 
five or ten grains. It has also been very highly recommended for the 
purpose of destroying organic tissues of low type. Thus, in diphtheria 
the most remarkable results are claimed from its use, Dr. A. Jacobi 
( Therap. Gaz., ii.) affirming, for instance, that in a few hours it entirely 
removes diphtheritic membranes if it be freely applied every hour, or 
more frequently, in the form of a mixture of one part of papain and 
two parts each of water and glycerin. It has also been employed for 
the destruction of the thickening of chronic eczema, of warts , of pyogenic 
membranes surrounding old sinuses or abscesses, and even of epithelioma. 
It is not caustic, but simply dissolves the diseased tissues, and is said to 
cause no pain. (See Birmingham Med. Rev., May, 1886.) In experi¬ 
ments at the University of Pennsylvania commercial papain of the 
most esteemed brand failed to exert any solvent power over albumi¬ 
nous substances; and in the practical use of the remedy the practi¬ 
tioner should be careful to see that the material employed is active. 


FAMILY IV-ABSORBENTS. 


This class contains remedies which are used for the purpose of 
absorbing acrid and deleterious materials, such as offensive discharges 
on the exterior of the body, and acrid secretions, or the irritant prod¬ 
ucts of the partial decomposition of food, in the alimentary canal. 
For the first purpose very fine dry earth and plaster of Paris are used 
to some extent in practice; but, as their employment is purely in the 
province of the surgeon, I shall say no more about them here. 

CHARCOAL. 

Charcoal is officinal in the U.S. Pharmacopoeia in two forms: 

Carbo Ligni. — Charcoal prepared from wood. 

Carbo Animalis. — Animal Charcoal , prepared from bone. 

Charcoal for medicinal purposes should be made out of a light, 
porous wood: that prepared from the young shoots of the willow or 
of the poplar is almost exclusively employed. It is a black, brittle sub¬ 
stance, and should have more or less lustre. It has a very remarkable 
power of absorbing many times its own bulk of gases, and, when ex¬ 
posed to the air, increases rapidly in weight. It should therefore, when 
intended for medicinal purposes, be powdered as soon as it is burnt, 
and put in small, completely-filled, closely-sealed bottles. 

Animal charcoal, or bone-black , formed as it is by the partial burning 
of bones, contains a large percentage of the phosphate and the car¬ 
bonate of calcium. Although this does not interfere with its strictly 
medical employment, it does with many of its uses in pharmacy; and 
consequently the U.S. Pharmacopoeia directs that a Purified Animal 
Charcoal ( Carbo Animalis Purificatus ) be prepared by digesting ordinary 
animal charcoal in dilute muriatic acid, by which all the lime salts are 
dissolved out, washing thoroughly with water, and heating to redness. 

Bone-black possesses absorbing powers far greater than those of 
ordinary or wood charcoal, and takes up coloring-matters, alkaloids, 
and other substances from solutions: it is therefore very extensively 
used in pharmacy, as well as in the refining of sugar, and in other 
processes of the arts. 

Therapeutics. —Charcoal is used externally as an absorbent and 

857 




858 


EXTRANEOUS REMEDIES. 


disinfectant dressing to foul wounds and ulcers. A charcoal poultice may 
be made by adding one to three drachms (according to size) of pow¬ 
dered charcoal to a flaxseed poultice; or, as the British Pharmacopoeia 
directs, two ounces of bread may be well mixed with ten ounces of 
warm water, an ounce and a half of flaxseed meal thoroughly stirred 
in, and to the cataplasm thus formed two drachms of powdered char¬ 
coal added, and one drachm sprinkled on the surface. 

Internally, charcoal is employed as an absorbent in those cases of 
acute or chronic indigestion in which there are offensive liquids and 
gases in the alimentary canal, giving rise to local symptoms and foul 
discharges: in this way it is sometimes employed in dyspepsia , cardi- 
algia , and similar disorders. It is at least conceivable that charcoal 
given very freely should accumulate in the alimentary canal and me¬ 
chanically cause serious trouble: for this reason, its habitual employ¬ 
ment is generally combined with that of laxatives. 

On account of its power of absorbing alkaloids, purified animal char¬ 
coal has been recommended in poisoning by substances of that class. 
Its action is, however, too slow for much good to be expected from its 
use. If given at all, it should be exhibited very freely, since at least 
half an ounce of it is said to be required for the absorption of one grain 
of the poison. 

Administration. —The ordinary dose of charcoal is from half an 
ounce to one ounce. Except in a mechanical way, it is perfectly in¬ 
nocuous in any dose. 


FAMILY V.—DISINFECTANTS. 


Disinfectants are substances employed, for the prevention or de¬ 
struction of noxious miasmata or effluvia. It is evident that the con¬ 
sideration of these materials belongs to the province of hygiene rather 
than to that of therapeutics, since their employment is hygienic rather 
than medicinal, preventive rather than curative. The importance of 
disinfection is, however, so great that I shall treat of it, although very 
briefly. For further details the reader is referred to the classical work 
of Tallin and the able report of the Committee of the American Public 
Health Association, 1885. 

All disease-poisons may be divided into those which are generated 
or multiplied within the human body and those which arise solely with¬ 
out the body. To the former I shall apply the term “ contagions,” to 
the latter the term “ miasms.” Of the nature of miasms we have no 
definite knowledge, but it is probable that in many, if not all, cases 
they are organic entities. It is certainly established in regard to very 
many contagions that they are living forms, and for practical purposes 
all contagions must be considered to be of such nature. In the experi¬ 
mental study of the power of poisonous agents over the contagions, we 
are forced to take as the measure of the power of such agents the in¬ 
fluence which they exert over the lower forms of life. We have no 
better criterion for judging of the effectiveness of disinfectant agents 
upon miasms. It must be remembered that these poisons are not 
necessarily connected with bad odors, but may in a most deadly form 
saturate the air in an apparently clean chamber, while the emanations 
from the most stinking cesspool may be free from them. It is proba¬ 
ble, however, that foul gases are of themselves able to produce systemic 
depression, although not definite disease. It is, therefore, always im¬ 
portant to prevent the giving off of foul gases from masses of decom¬ 
posing matter. 

An antiseptic is not always a germicide , though a germicide is always 
an antiseptic. The antiseptic is a substance which has the power of 
preventing putrefaction,—that is, the growth of the organisms which 
produce putrefaction; whereas the germicide is a substance which is 
capable of killing disease-germs and their spores, which entities are 
much more resistant than are the bacteria of putrefaction: thus, alcohol, 
common salt, borax, sulphate of iron, and many other agents commonly 
used as antiseptics do not even in concentrated solution destroy the 
spores of bacilli, and consequently are not germicides. 


859 



860 


EXTRANEOUS REMEDIES. 


A question of very grave importance naturally arises here, as to the 
exact province of disinfection when applied to contagions; or, in other 
words, Is it possible to destroy them in the air ? It is a law which 
holds everywhere, that the more imperfectly developed animal organ¬ 
isms are, the more tenacious are they of life; also experience has 
shown that all substances actively poisonous to contagions are still 
more poisonous to the germinal matter of human beings, and that it 
may be laid down as a general proposition that it is impossible to de¬ 
stroy the contagion-germs in the confined air of a room while men 
or women remain in the apartment. When it comes to the general 
atmosphere, to attempt to disinfect it, to essay the destruction of a 
wide-spread poison, such as, for example, exists in a smallpox epidemic, 
is simply so childish as to need no discusssion to show its utter futility.* 
It is well known that contagions diluted beyond a certain point are 
powerless, and the admission of large quantities of fresh or pure air, 
or, in other words, free ventilation , is the only means at our command 
of disinfecting rooms in which there are human beings. In ventilating 
an apartment, it must always be remembered that it is not merely air, 
but pure air, that is required. To ventilate one room into another, as 
is sometimes done, is foolishness; to open a window with the wind 
blowing over a miasmatic swamp or an open sewer may be but to invite 
disease. The opportunity to destroy disease-germs is to be found not 
after they have been dispersed into the air, but while they are still in 
connection with the various solids and fluids passed from the body or 
brought in contact with it. In most, if not all, contagious diseases the 
poison-germs are eliminated in large quantities with the urinary and 
fsecal discharges; it is of vital importance to act on the excretions as 
soon as they leave the body; and the disinfectant should be placed in the 
receptacle before , not after, it is used. To allow any excretion, sputum, 
or other infected discharge to exist for a moment undestroyed, or at 
least undevitalized, is most culpable neglect. Spit-cups, urinals, etc., 
should therefore have the disinfectant in them whilst waiting for use. 

The nature of miasms is not known. Over many of them—mal¬ 
aria, for example—we have no control. Those which we are able to 
influence are almost all the results of animal or of vegetable decompo¬ 
sition, either alone or conjoined. After these poisons have been pro¬ 
duced and diffused through the air, they are probably in great part 
beyond our reach. The only thing that can be done is to dilute them, 
precisely as in regard to contagions; and hence free ventilation is the 
only reliable disinfectant under these circumstances. The stinking 
gases are probably of use aa indicators of the presence of more subtile 
poisons. The gases which arise from cesspools and similar depositories 
no doubt act as carriers of the peculiar poisons produced in these 
places, and it may be that destruction of the gas causes a deposition 


* For failure of such an’attempt, see New Orleans Med. and Surg. Journ., Nov. 1875. 



DISINFECTANTS. 


861 


of the organic poison. This is, however, merely speculation: it is not 
proved. Moreover, the deposition of a poison in an apartment is no 
advantage. Even if it were possible to make an apartment appear 
to the smell pure by destruction of its stinking gases, no good would be 
accomplished by so doing. Wide-open windows, great draughts of fresh 
air, are the only proper disinfectants for a close room or a noisome 
hospital-ward. The attempt so often indulged in to purify such apart¬ 
ments by little saucers of chlorinated lime or of carbolic acid would be 
exceedingly ludicrous if it were not for the frightful results of the false 
sense of security engendered. 

It is otherwise when the gases are destroyed at their places of 
emanation. Thus, if a sewer be belching forth deleterious gases and 
poison, chlorinated lime or other materials generating disinfecting gases 
at the mouth, or in the sewer, may really be of service by destroying 
the noxious vapors before they find their way out and carry with them 
into the air the poisonous effluvia. 

Although miasms cannot be readily destroyed when once generated, 
yet in very many instances we have power to prevent their formation. 
In doing this the chief factor is cleanliness , and the best disinfectant is 
water . Water acts chiefly in two ways: first, by dilution; secondly, by 
destroying organic substances. In order for decomposition to produce 
serious poisoning, the mass of material must be considerable. If the 
matter be diffused through a large bulk of water, and this spread over 
a considerable surface, it is evident that the effect of dispersion is ob¬ 
tained. Further, when water containing organic matter is allowed to 
run away in its natural channels, oxidation and destruction of the im¬ 
purities result. Without entering further into the subject, it is suffi¬ 
ciently evident that, so far as miasms, and also disease-germs in the air, 
are concerned, air and water are the great disinfectants , and that the 
most skilful use of chemical substances cannot take the place of venti¬ 
lation and cleanliness. Moreover, antiseptics may do harm by delaying 
the destruction of filth by putrefaction, which latter process is simply 
nature’s method of getting rid of filth. Destructive—that is, oxidizing 
—disinfectants, rather than antiseptics, should be used in cesspools. On 
the other hand, when the contents of a privy or other organic mass 
has been infected by disease-germs, it is essential to kill such germs by 
a germicidal agent. 

The most complete and thorough, but the most destructive, of all 
disinfecting agents is fire. Heat of less intensity may be used either 
moist or dry. In the early part of the present century Dr. Henry, of 
Manchester, showed that the activity of vaccine lymph is destroyed by 
moisture at 140° F. in four hours. Drs. Carsten and Coert have also 
proved that calf lymph is at once sterilized by boiling water. Dr. George 
N. Sternberg found that boiling water will quickly destroy the vitality 
of all organisms known as disease-germs. This accords with the experi¬ 
ments made with hot air in the laboratory of Koch, in which it was 


862 


EXTRANEOUS REMEDIES. 


found that all bacteria are killed by an exposure of one hour and a 
half to the temperature of 212° F. with moisture. Similar results have 
also been arrived at by other experimenters, and I think it may be con¬ 
sidered as established that all non-spore-bearing infectious bacteria are 
destroyed by water or steam at a temperature of 212° F. The spores 
of the bacilli have, however, much greater powers of resistance. Dr. 
Sternberg found that boiling for two hours does not kill the spores 
of Bacillus subtilis, although a more prolonged boiling is fatal, but that 
steam at a temperature of 110° C. (230° F.) for one or two minutes, or 
105° C. (220° F.) maintained for ten minutes, will infallibly kill the 
spores. If dry instead of moist heat be employed, a much higher de¬ 
gree of temperatui-e will be required. In the experiments of Koch and 
his assistants with dry hot air, the spores of mildew required for their 
destruction exposure for an hour and a half to a temperature of 230° F., 
the spores of bacilli an exposure of three hours to a temperature of 
204° F. All observers find that the addition of steam to dry air in¬ 
creases greatly its destructive effect. Wolf ( Virchow's Archiv, vol. cii. 
p. 81) found that dry air at 140° C. was scarcely more destructive than 
watery vapor at 100° ; Koch, that five minutes’ exposure to steam was 
equal to an hour or an hour and a half with the dried air. The results 
reached by Koch and Wolffhiigel (Mitt. Kais. G-esundheitsamte, Bd. i.) 
are in accord with our other evidence, and may be considered correct. 
They are as follows: 

1. A temperature of 100° C. (212° F.), dry heat, maintained for one 
hour and a half, will destroy bacteria which do not contain spores. 

2. Spores of mould-fungi require for their destruction in hot air a 
temperature of from 110° to 115° C. (230°-239° F.) maintained for one 
hour and a half. 

3. Bacillus-spores require for their destruction in hot air a tempera¬ 
ture of 140° C. (284° F.) maintained for three hours. 

4. In dry air the heat penetrates objects so slowly that small pack¬ 
ages, such as pillows or small bundles of clothing, are not disinfected 
after an exposure of from three to four hours to a temperature of 
140° C. (284° F.). 

5. Exposure to a temperature of 140° C. (284° F.) in dry air for 
a period of three hours injures most objects requiring disinfection 
(clothing, bedding, etc.) to a greater or less degree. 

Dr. George H. Rohe (Med. News , 1885, i. 283) found that rolls of 
blankets exposed in a chamber heated to 280° F. for three hours were 
very slightly affected in their interior. This is in strict accord with 
the teaching of Drs. Parsons and Klein, of the London Local Govern¬ 
ing Board ( Report , 1885), and of other observers. I think that the 
superiority of prolonged boiling over other methods of application 
of heat is established. In the sick-room, objects which can be boiled 
without injury should, immediately after their infection, be gathered 
into a close bundle, enclosed in a sheet, and as soon as possible thrown 


DISINFECTANTS. 


863 


into boiling water without opening. When pillows, bedding, or arti¬ 
cles of furniture are seriously affected, they should be taken apart and 
exposed to heat and steam. For further details as to apparatus the 
reader is referred to the report of Parsons and Klein, already alluded to. 

LEAD AND IRON. 

There are various metallic salts which are believed to act as disin¬ 
fectants by uniting with the sulphur of sulphuretted gases and precipi¬ 
tating as sulphurets. As examples of such may be mentioned sulphate 
of zinc and nitrate of lead. Under the name of Dedoyen's Disinfectant 
Solution , a solution of the latter salt has been and still is used to a con¬ 
siderable extent as a disinfectant. Although it certainly destroys sul¬ 
phuretted hydrogen with great rapidity, it does not seem to me a good 
material for the purposes to which it is applied. The reasons for this 
are—first, it has no action besides that of a desulphurating body; second, 
it is a comparatively dear salt; third, it forms an intensely black pre¬ 
cipitate, discoloring everything with which it comes in contact. 

The power which the oxides of iron have of converting ordinary 
oxygen into ozone has already been spoken of (p. 473). This action is 
a slow, persistent one, and the oxidation which results is equally slow 
and persistent. As already stated, organic matter, if diffused through 
water and exposed to the air, is gradually destroyed by oxidation. It 
has been found that when water which is loaded with the products of 
decomposition is exposed to the action of iron plates, or even of iron 
pipes, this destruction of organic impurities is greatly hastened. Ac¬ 
cording to Mr. G-. Michaelis ( Phila. Med. Times , vol. iii. p. 621), even 
the most filthy water, under the influence simply of iron plates and the 
air, will become perfectly pure in forty-eight hours. The action is evi¬ 
dently one of oxidation, but is in its details complicated. According 
to the researches of Dr. Mankiwich, iron possesses the property of con¬ 
verting ammonia into nitric acid, and also facilitates, or even provokes, 
such decomposition in the organic matter as shall cause ammonia to be 
formed. The nitric acid thus generated is one of the most powerful 
oxidizing substances known, and as fast as formed attacks the organic 
matter. It is evident that in this process the iron acts as an inter¬ 
mediate agent between the air and the decomposing matter; that, 
unlike the permanganate of potassium, it does not itself undergo a 
conversion equivalent in chemical relation to the oxidation, and conse¬ 
quently that its power is not so limited as that of those compounds. 
The iron, however, undoubtedly suffers to some extent, and is largely 
oxidized; but the oxide formed has certainly the power of generating 
ozone, and very probably to as great an extent as the original metal. 
How soon the power of oxidation is finally lost, and what eventually 
becomes of the iron, in the presence of an overwhelming mass of 
organic matter, has not, that I am aware of, been determined. 


864 


EXTRANEOUS REMEDIES. 


Copperas, or impure sulphate of iron, is an important destroying dis¬ 
infectant, although, according to recent experiments, it has no germi¬ 
cidal power.* The changes wrought by sulphate of iron thrown into 
a mass of decomposing matter are very complex and not absolutely 
known. In the first place, if sulphuretted hydrogen and ammonia are 
present, a sulphuret of iron is at once precipitated ; again, a part of the 
salt is decomposed by the ammonia, and probably also by the stink¬ 
ing alkaloids which exist in the decomposing mass of a cesspool; fur¬ 
ther, by oxidation, in all probability, some of the protoxide of iron is 
changed into the sesquioxide, by which the ozonizing power of an iron 
compound is doubtless exerted long after the destruction of the original 
salt. The sulphuric acid set free from the iron very probably takes 
part to a feeble extent in the destructive reactions which are set up. 
From what has been already stated, it is evident that the sole use of 
the copperas is in altering the course of putrefaction and in destroying 
its products. If a rapid effect is desired, or if a mass of solid material is 
to be acted on, the copperas should be in solution; if a more persistent 
action is wanted, or if the mass is liquid, the method employed by Eck¬ 
stein, of using a parchment sack, may be resorted to, or the salt in powder 
may be scattered over the surface of the material to be disinfected. 

Lime is probably the oldest of all the disinfectants, but is of value 
only as a destructive agent,— i.e., as causing a slow oxidation of or¬ 
ganic matter. It is notorious that a compost-heap to which lime has 
been added rots— i.e., oxidizes—much more rapidly than one which has 
none of the alkaline earth in it. This action of lime is, however, too 
slow for ordinary purposes: moreover, there are very serious objections 
to the use of lime as a disinfectant. 

The poisonous principles contained in sewage, etc., whatever their 
nature may be, are probably volatile, and lime, acting as a strong base, 
sets free large quantities of ammonia in animal matter undergoing de¬ 
composition. It may be that volatile poisons, alkaloids, are liberated 
with the ammonia; but, whether they are or not, it is a well-known 


* That this substance is of great practical value for use in cesspools, etc., is strongly indi¬ 
cated by the experiments of Albert Eckstein, who published ( Zeitschrift den 0 eater. Apotheker- 
Vereinea, Feb. 10, 1873) an account of his attempts to disinfect a privy which was used 
daily by one hundred persons: 1. Two pounds of the sulphate of iron in solution were 
used. After from two to three hours all bad smell had disappeared, but in twelve hours all 
the influence of the disinfectant was lost. 2. The sulphate of copper was employed in solu¬ 
tion ; result the same. 3. Two pounds of the sulphate of iron in crystals were thrown in; 
their effects lasted two days. 4. The sulphate of copper, the same. 5. Sulphurous acid in 
solution rapidly lost its effect, and was exceedingly irritating to the respiratory organs. 6. 
Two pounds of impure carbolic acid filled the house for two days with so disagreeable a 
smell that it was impossible to tell whether the original odor was destroyed or covered up. 7. 
Two pounds of sulphate of iron in a parohment sack exerted a disinfecting influence for three 
full days, and when the parchment sack was drawn up it contained only some dirty, odorless 
fluid. 8. Two pounds of the best chlorinated lime in the parchment sack disinfected the 
privy for at least nine days. 



DISINFECTANTS. 


865 


physical fact that a volatile substance in escaping carries off with it 
even non-volatile materials, and facilitates to a still greater degree tho 
escape of principles only less volatile than itself. 

Lime is, for the above reasons, not available for use as a disinfectant 
in cesspools and sewers unless it is added in large quantities day by 
day from the beginning, so as to keep the collection under its influence, 
and unless some absorbent is added with it to take up volatile prin¬ 
ciples. In the ordinary open privies of the country, a shovelful of a 
mixture of lime and plaster of Paris, or of lime and dry earth, thrown 
in day by day, will tend to prevent odor, and at the same time will 
prepare the contents for use as manure. 

When spread upon walls in the form of whitewash, lime may act to 
some extent as an oxidizer,- but probably its chief influence is as an 
absorbent, which takes up the deleterious emanations. A very striking 
illustration of this action of whitewash occurred some years since in 
the New York city hospital. A ward which stood isolated from the 
remainder of the institution had been used for the reception of cases 
of typhus fever from the shipping of the port. It was finally aban¬ 
doned and allowed to stand unoccupied, with its windows wide open, 
for several months. At the end of this time, a gang of men were 
set to scraping the whitewash off the walls. Of these workmen a 
majority were seized with the ship-fever, and several died. 

CORROSIVE SUBLIMATE. 

In 1870, Dr. John Dougall announced that corrosive sublimate one 
part in sixty-five hundred would kill spermatozoa, and one part in six 
thousand infusoria; the later researches of Koch, Jalan de la Croix, 
and Sternberg have more than confirmed this result, and shown that 
corrosive sublimate is one of the most powerful of known germicides. 
Micrococci and bacilli in active growth without spores are killed by 
solutions of one in twenty thousand, while solutions of one in one 
thousand will rapidly destroy the spores of B. anthracis and B. subtilis. 
Results contrary to these have, it is true, been obtained by Klein of 
London, who asserts that a one-per-cent, solution of the mercuric 
chloride is no more a germicide than is vinegar; but the evidence 
to the contrary is so strong that it seems almost a certainty that 
there is some error in Klein’s experiment. According to the de¬ 
tailed experiment of Koch, the spores of B. anthracis are absolutely 
incapable of germinating in a proteid solution if as little as one part 
of corrosive sublimate in three hundred thousand be present. Dr. 
Sternberg confirms the experiments of Koch, and it would theoreti¬ 
cally appear that one part of corrosive sublimate in one hundred 
thousand is sufficient to destroy germs in a mass of filth, provided the 
filth is so situated that the corrosive sublimate will remain in contact 
with it for some time. It must be remembered, however, that cor¬ 
rosive sublimate is readily decomposed by the ammonia and other 


866 


EXTRANEOUS REMEDIES. 


chemical substances in a mass of filth, and it is very doubtful whether 
in practice it will be found that the mercuric chloride is available for 
disinfectant purposes on a large scale. Even, however, if its powers 
be considerably less than they appear to be, it would still remain for 
many purposes the best of all germicides. A standard solution of one 
part in a thousand may be used for bedding, which can be soaked in it, 
for washing the floors and walls of infected apartments, and for disin¬ 
fecting the hands of surgeons and gynaecologists; after the corrosive 
sublimate has done its work it should be removed by free washing with 
pure water. For the destruction of germs in faecal discharges, the solu¬ 
tion should have at least the strength of one part in five hundred. 

In regard to the use of corrosive sublimate in the treatment of 
wounds, etc., the reader is referred to treatises on surgery. It is, how¬ 
ever, proper here to state that a number of cases of death from the 
local use of corrosive sublimate, especially in obstetrical and gynaeco¬ 
logical practice, have been reported. In most of these cases the solution 
has been at least one part in fifteen hundred; but I have known the use 
of a vaginal wash one in ten thousand to be followed by severe poi¬ 
soning. It is probably very rarely proper to use continual irrigation 
of a mucous surface or of a wound with a solution stronger than one 
in ten thousand; and for a single washing the solution should not be 
more than one in two thousand. 

CARBOLIC ACID. 

Carbolic acid is an active and much-used germicide. For an account 
of its properties, see Acidum Carbolicuh, p. 594; of its disinfectant 
value and use, p. 606. 

POTASSII PERMANGANAS—PERMANGANATE OF POTAS¬ 
SIUM. U.S. 

(K0,Mn 2 0 7 — Mn 2 0 8 K 2 .) 

This salt is prepared by heating together ten parts of binoxide of 
manganese and twelve parts of potassa. It occurs in slender, prismatic 
crystals of a dark-purple color, inodorous, of a sweetish, disagreeable 
taste, and very soluble in water, with which they form a solution vary¬ 
ing from a purplish black to a beautiful reddish lilac, according to the 
strength. When kept dry and not exposed to the atmosphere, per¬ 
manganate of potassium is a permanent salt, but whenever in solution 
it is brought into contact with an organic body it at once gives up its 
oxygen to the latter and is converted into potassa and black oxide of 
manganese. 

The disinfectant power of this salt is beyond question; but at the 
same time this power is very limited, as the remedy yields up its own 
oxygen and becomes inert. According to the experiments of Dr. George 
M. Sternberg (Med. News , Jan. 10, 1885), as a germicide the perman¬ 
ganate is very potent, 0.12 per cent, (one part in eight hundred and 


DISINFECTANTS. 


867 


thirty-three parts) killing the micrococci of pus in two hours. For 
practical purposes, however, this agent is of very little value as a ger¬ 
micide, because it is at once decomposed by organic matters, and while 
in the laboratory disease-germs may exist almost isolated, in the sick¬ 
room they are mixed with a large excess of organic material. Never¬ 
theless the permanganate affords a very elegant disinfectant and ger¬ 
micidal wash for wounds, ulcers, abscesses, etc., fetid ozcena, otorrhcea , 
leucorrhcea, etc. In dilute solution its local influence is stimulant and 
beneficial. When employed in the form of powder it even affects living 
tissues, acting as a mild caustic, and, as such, may often be applied with 
advantage to sloughing ulcers. As a wash, the strength may vary ac¬ 
cording to circumstances, from one to twenty grains to the ounce. 

CHLORUM—CHLORINE. 

Chlorine gas is officinal only in the form of the Aqua Chlori, which 
is prepared by heating together black oxide of manganese and hy¬ 
drochloric acid, and allowing the chlorine which is generated to pass 
through water until the latter is saturated. Chlorine Water is a green¬ 
ish-yellow liquid, of a very sharp taste, and having a strong odor of 
chlorine. When it is desired to liberate chlorine in the air of a room, 
eighteen parts of finely-ground common salt with fifteen parts of finely- 
powdered black oxide of manganese should be introduced into a flask; 
then there should be added forty-five parts of concentrated sulphuric 
acid and twenty-one of water, previously mixed and completely cooled; 
and, lastly, the flask is to be well shaken. When the evolution of gas 
eeases, it may be renewed by placing the flask in warm water.* When 
chlorine is brought into contact with organic substances and moisture, 
it unites with the hydrogen of the water and liberates nascent oxygen, 
which rapidly oxidizes and destroys the organic compound. When 
chlorine comes in contact with sulphuretted hydrogen, it removes its 
hydrogen and thereby desti-oys it. 

The germicidal influence of chlorine is very great. Fischer and 
Proskauer found that dried anthrax spores maintained their integrity 
for one hour when exposed to the action of a dry chlorine atmosphere 
containing 44.7 parts of chlorine in 100. When the air and the spores 
were moist, one hour’s exposure to an atmosphere containing four per 
cent, of chlorine produced complete disinfection. If the exposure was 
continued for three hours, one per cent, of chlorine was an efficient 
germicide; and if the spores were exposed for twenty-four hours, the 
effective proportion of chlorine could be still further reduced. In Dr. 
Sternberg’s experiments (Rep. Nat. Bd. of Health, 1880), six hours’ 
exposure of vaccine lymph dried upon ivory points to an atmosphere 


# Inspired in sufficient amount, chlorine gas produces, both in man and in the lower ani¬ 
mals, narcotism, and finally death from paralysis of the respiratory centres (consult Arch. f. 
Exper. Path. u. Pharm., xiii.). 



S68 


EXTRANEOUS REMEDIES. 


containing one part of chlorine in two hundred was sufficient to de¬ 
stroy the infective property of the lymph, while the bacteria of putrid 
urine were destroyed after six hours’ exposure to an atmosphere con¬ 
taining one part of chlorine in four hundred. Dr. Klein also found 
(Report of the Local Governing Board , vol. xiii., 1883 and 1884, Supple¬ 
ment) that after the compartment of a stable in which pigs had died 
of swine-plague had been thoroughly fumigated for six hours with 
chlorine, healthy animals could be placed therein with safety. 

The result of all our knowledge upon the subject of the disinfectant 
properties of chlorine , iodine , and bromine is summed up by Dr. Geo. H. 
Kohe (Med. News , xlvi. 89) as follows: 

1. Chlorine is an efficient disinfectant when present in the propor¬ 
tion of one part in one hundred, provided the air and the objects to 
be disinfected are in a moist state and the exposure continues for up¬ 
wards of an hour. 

2. Chlorine, when used in sufficient concentration to act as a trust¬ 
worthy disinfectant, injures colored fabrics and wearing-apparel. 

3. Bromine is an efficient disinfectant in the proportion of one part 
in five hundred, provided the air be in a moist state and the exposure 
continues for upwards of three hours. 

4. Iodine, in solution, is an efficient disinfectant in the proportion 
of one part in five hundred, the exposure continuing for two hours. 

5. The use of chlorine, and in a greater degree of bromine, requires 
considerable experience in management: when carelessly handled they 
may cause inconvenient or even dangerous symptoms in persons using 
them; hence they are not suitable as disinfectants for popular use. 

Internally, chlorine water has been used in various diseases, es¬ 
pecially in malignant typhus , but at present is rarely if ever so em¬ 
ployed. It is stated to be stimulant and tonic to the stomach, and is 
thought by some to have an especial influence upon the liver. It has 
been employed in chronic hepatic affections ; the dose is half a fluidrachm 
to two fluidrachms in three or four fluidounces of water. Chlorine 
water is a powerful irritant, capable of producing severe inflammation 
of the skin or toxic gastro-enteritis. Properly diluted, it forms an ex¬ 
cellent stimulant, disinfectant, detergent wash for foul ulcers , and may 
also be used as a gargle in malignant sore throat. 

Calx Ciilorata — Chlorinated. Lime. U.S.—In ordinary life chlorine 
is chiefly used as a disinfectant in the form of a grayish-white substance 
occurring in powder or friable lumps, having a hot, acrid, astringent 
taste, and an odor resembling that of chlorine. It is made by the 
action of chlorine upon hydrate of calcium, or slaked lime, and should 
contain at least twenty-five per cent, of chlorine. It probably varies 
in its chemical constitution, but, according to the most recent views, 
is chiefly composed of the hypochlorite and the chloride of calcium. 
When exposed to the air it slowly evolves hypochlorous acid, which, 


DISINFECTANTS. 


869 


being an unstable compound, undergoes spontaneous decomposition, 
and finally sets free fourteen-fifteenths of its chlorine. When an acid 
is added to chlorinated lime, the chlorine gas is rapidly evolved. If a 
specimen of bleaching-powder be very moist, it generally contains an 
over-proportion of the deliquescent chloride of calcium, and is corre¬ 
spondingly unable to liberate chlorine. 

The experiments of Dr. J. ft. Duggan (Med. News, xlvi. 147) indi¬ 
cate that the hypochlorites are among the very best of our practical 
disinfectants. He found that 0.25 of one per cent, (one part to four 
hundred) of chlorine as hypochlorite is an effective germicide even 
when allowed to act for only two minutes; while 0.06 of one per cent, 
(six parts to ten thousand) will kill the spores of B. anthracis and B. 
subtilis in two hours. 

Bleaching-powder usually contains from twenty-five to forty per 
cent, of available chlorine. For most purposes, a solution containing one 
part of this preparation to one hundred parts of water is strong enough, 
for this will contain from 0.25 to 0.40 of one per cent, of chlorine as 
hypochlorite. As is stated above, the smaller of these quantities is 
sufficient to destroy spores almost instantly. There are very few pur¬ 
poses to which disinfectants are applied that are not fulfilled by this 
solution of one to one hundred of bleaching-powder. It is not danger¬ 
ously poisonous, is said not to injure clothing, bedding,* etc., and is 
very cheap, since bleaching-powder is worth only about five cents per 
pound.f For the destruction of disease-germs in urine, fcecal discharges, 
sputum, etc., a saturated solution of bleaching-powder appears to be in all 
respects the best disinfectant known. 

Liquor Sodas Chlorate, U.S.— Solution of Chlorinated Soda, or 
Labarraque's Solution, is an officinal preparation made by triturating 
chlorinated lime with a solution of the carbonate of sodium. It is a 
greenish-yellow liquid, having a slight odor of chlorine and a sharp 
saline taste. It contains, among other substances, hypochlorite of 


* This statement seems to me doubtful. 

f To fix the value of solutions of the hypochlorites, the following method is, according to 
Duggan, sufficiently accurate for ordinary purposes. A standard solution of potassium arsenite 
may be made by diluting seven parts of Fowler’s solution with one and a half parts of water. 
This corresponds to a one-half-per-cent, solution of available chlorine. To apply the method, 
a given volume of the hypochlorite solution is measured out, and the arsenite solution added 
in small quantities. Between each addition the mixture is well stirred, and a drop taken out 
on a glass rod and tested on a strip of paper saturated with iodide of potassium and starch 
paste and dried. As long as any hypochlorite is present, the blue iodide of starch is formed; 
but when it has all been used up in converting the arsenite into an arseniate, the paper will 
remain colorless. As each volume of the potassium arsenite solution required for this corre¬ 
sponds to one-half per cent, of available chlorine, the calculation is very simple: e.g., if one 
volume of the hypochlorite solution = 4.6 volumes of the arsenite solution, the amount of 
available chlorine present would correspond to 2.3 per cent. Since the preparations now on 
the market vary so much in the amount of chlorine they contain, this test should always be 
used to determine their value and the amount of dilution required. 



870 


EXTRANEOUS REMEDIES. 


sodium, and possesses the therapeutic and disinfectant properties of 
the chlorinated compound. Owing to its liquid form, its comparative 
freedom from odor, and its depositing chloride of sodium on evapora¬ 
tion, it is the most elegant of all the chlorine preparations for use in 
the sick-room. Properly diluted, Labai’raque’s solution may be em¬ 
ployed for all the therapeutic purposes that chlorine water is used for. 
The dose is half a fluidrachm to two fluidrachms, in half a tumblerful 
to a tumblerful of water. 

ACIDUM BORICUM—BORIC ACID. U.S. 

Sodii Boras, U.S.— Borax. —Boric (or Boracic ) acid crystallizes in 
white translucent scales, soluble in about thirty parts of cold water, 
much more soluble in boiling water, which on cooling precipitates all 
but about twenty-three grains to the fluidounce. Hot glycerin dissolves 
and holds upon cooling as much as three drachms to the fluidounce. 
Borax occurs in white, flattened, prismatic crystals, soluble in twelve 
times their weight of cold water. 

The action of boracic acid and its salts upon the animal system is a 
very feeble one. In experiments made by Dr. B. T. Stewart and my¬ 
self, enormous doses were required to affect the frog; they depressed 
the spinal centres and produced progressive loss of voluntary and reflex 
activity without affecting nerve or muscle. A saturated solution of the 
quadroborate of sodium brought in direct contact with the heart exer¬ 
cised a very feeble depressant influence, and when injected in suffi¬ 
cient amount into the jugular vein of the mammal lowered the arterial 
pressure. Cyon ( Hoffmann und Schwalbe's Jahresb ., 1879, 301) found 
that daily doses of three drachms of borax increase the appetite and 
digestion in dogs without causing other effect, unless it be gain in 
weight. Max Gruber* (Ibid., p. 351), in a series of experiments, found 
that the elimination of urea and of water by the kidneys is increased 
by large doses of borax. Mododewkow is said (St. Louis Clin. Bee., 
Sept. 1881) to have had two cases of fatal poisoning with boracic acid: 
in the one patient a lumbar abscess, in the other a pleuritic cavity, was 
washed out with a five-per-cent, solution of the acid, much of which 
remained. The symptoms were nausea, incessant vomiting, hiccough, 
erythematous eruption, fall of temperature, and collapse, the mind re¬ 
maining clear. In a not fatal case (Med. News , xl. 704) the symptoms 
were erythema, with rapid, feeble pulse. Hogner reports (Schmidt's 
Jahrb., ccii. 238) two cases in which washing out of a dilated stomach 
with a two-and-a-half-per-cent. solution of boracic acid was followed by 


* A very curious effect is said (by Professor Schiff, Rev. Mid. de Suisse Rom., 1881, 244) 
to be produced by the local application of boracic acid to nerves: the part affected is affirmed 
to lose its power of originating but not of transmitting impulses, so that if the galvanic cur¬ 
rent be applied to the part of the nerve which has been exposed to the drug no muscular 
contractions result, but if the poles be placed above this part the distal muscles respond at 
once. 



DISINFECTANTS. 


871 


erythematous eruption, headache, great general distress and weakness, 
disturbance of respiration, coma, involuntary discharges, ecchymoses 
on the skin, and death.* Dr. Johnson ( Therap. Gaz., iii. 114) finds that 
boracic acid appears in the urine in ten minutes after the ingestion of 
it or of borax, and that it may also be recovered from the perspiration, 
saliva, and faeces. He states that it is distinctly diuretic, and that in 
some cases of albuminuria he has succeeded with it in reducing, or 
even in causing to disappear entirely, the albumen. 

In 1874, Dumas and Schnatzles announced that borax is poisonous 
to the lower forms of life ( Pharm. Journ., April, 1874); in Bucholz’s 
experiments, 0.75 per cent, of boracic acid was found sufficient to pre¬ 
vent the development of bacteria (Arch. f. Exper. Path. u. Pharm., Bd. 
iv.). In the experiments of Dr. Walb (Centralbl. f. Kim. Med., 1882, 
iii. 529), a two-per-cent, solution of borax distinctly checked the putre¬ 
faction of solution of fibrin; a five-per-cent, solution kept the solution 
fresh for nineteen days. Fresh muscle-fibres from oxen were kept 
fresh many days by a one-per-cent, solution. In the elaborate experi¬ 
ments of Dr. Sternberg it was found that boracic acid and the bibo¬ 
rate of sodium are inefficient as germ-destroyers, but have consider¬ 
able antiseptic power (Amer. Journ. Med. Sci., lxxxiv. 321). Boracic 
acid has, therefore, some antiseptic power, although further experi¬ 
ments are necessary to settle its exact value. The acid has been used 
to a considerable extent in antiseptic surgery, and it is affirmed to be 
free from irritating properties, and of great practical value in the treat¬ 
ment of fresh wounds, foul ulcers, abscesses, old burns, etc. (see espe¬ 
cially Dr. M. Greene, Boston Med. and Surg. Journ., ciii. 209). A lint 
may be made by saturating ordinary patent lint with a saturated boil¬ 
ing solution of boracic acid ; wounds dressed in a dry manner with this 
are stated to heal as rapidly as when a complicated antisepsis is em¬ 
ployed. Dr. Greene prepares an ointment by melting one part each of 
spermaceti and white wax with six parts of vaseline, and adding, while 
hot, two to four parts of a saturated glycerite of boracic acid. In the 
form of lotion, the remedy has been used with great advantage in 
phlegmonous erysipelas (see Lancet , May, 1873; May, 1876; also Pro¬ 
fessor F. L. Lebovicz, Gaz. Hehdom. de Med., 1884, xxi. 624). There 
can be no doubt of the value of boracic acid and borax as a local appli¬ 
cation in aphthous ulceration, diphtheria, and other inflammations of the 
mouth, in which crystals of the sodium salt may be allowed slowly to 
dissolve in the mouth; whether, as affirmed by Dr. William Greene and 
by Dr. F. P. Atkinson (Lond. Practitioner, xxiv. 254), boracic acid is 
useful in septicaemia, puerperal fever, erysipelas, etc., is more problem¬ 
atical.-}- Borax has been used in epilepsy with asserted good results, 


* There is no reason for believing that boric acid had anything to do with the symptoms 
in the case of alleged poisoning reported in Med. News, xliii. p. 199. 

f M. Cyon commends very highly the use of borax in daily doses of eighty to ninety 
grains as a prophylactic against cholera, and affirms that during the epidemic in Italy during 





872 


EXTRANEOUS REMEDIES. 


especially by Dr. C. F. Folsom ( Boston Med. and Surg. Journ., Feb. 18, 
1886). He gives ten to fifteen grains three times a day. I have tried 
it in a number of cases, the only result being marked gastro-intestinal 
irritation. The statement of Professor Rosenthal ( Allgem. Wien. Med. 
Wochens ., Jan. 1884) that boracic acid is efficient in ammoniacal urine 
and cystitis, acidifying the urine and checking the fermentation, has 
been confirmed (see Lancet , 1884, ii. 133). In the cystitis of spinal 
diseases I have secured great relief by washing out the bladder with a 
few ounces of a saturated solution of boracic acid after the use of the 
catheter. The acid may be given in doses of ten grains three to six 
times a day; the salt, twenty grains to a drachm: in each case admin¬ 
istered in diluted watery solution. As a disinfectant and soothing 
eye-wash its solution is much used by oculists in conjunctivitis. The 
strength may vary from five grains to the ounce up to saturation. 

ACIDUM SULPHUROSUM—SULPHUROUS ACID. 

Sulphurous acid and its salts are most efficient in destroying the low 
forms of life which are connected with putrefaction and fermentation, 
and for this reason are excellent preservatives of organic matters. 

Sulphurous acid and its salts are among the oldest of disinfectants, 
having been used as long ago as 1771; but recent experimental evidence 
seems to indicate that they have not the great superiority which has 
been attributed to them. According to the experiments of Sternberg, 
one volume of sulphurous acid gas in one hundred volumes of air is 
sufficient to disinfect dry vaccine matter. As these experiments are 
in accord with older observations, they may be considered as correct. 

According to Wernitz, the action of pepsine, of ptyaline, of inver- 
tine, and of diastase is prevented by the presence of an aqueous solution 
of S0 2 of 1: 1317 to 1: 8600 (by weight) ; while the action of myrosine 
and of emulsine is neutralized by 1 : 21,000. Wernitz further says 
that strips of woollen or cotton goods saturated with putrefactive 
matter are disinfected by exposure of from four to six hours to an 
atmosphere containing four per cent, of sulphurous acid gas. The 
very elaborate experiments of Koch, of Wolffhiigel, and of Sternberg 
have shown, however, that when the infectious material contains 
spores sulphur dioxide is of very little value. Wolff hiigel concludes 
that it should be abandoned as a disinfectant: nevertheless, as prob¬ 
ably but few of the contagions are in the condition of spores, it is 
likely that sulphurous acid, When sufficiently concentrated, is an effec¬ 
tive disinfectant, if applied for a sufficient length of time. It has been 
proved by the experiments- of Sternberg that the gas acts much 
more freely and powerfully when the air is loaded with moisture. 


1864-65 none of the villagers employed in the borax-works were affected, while in a village 
in close proximity one-third of the inhabitants died. He believes that the drug kills the 
germs in the alimentary canal ( Compt.-Rend . Acad. Sci., xcix. 149). 



DISINFECT A NTS. 


873 


Fumigation of an apartment with sulphurous acid gas should never 
be allowed to take the place of cleanliness and thorough disinfection 
of the walls and of all articles of furniture. Whether after all this is 
done the fumigation does any good—whether in practice it is of any 
real value—remains doubtful. It is perfectly sure that it is of no ser¬ 
vice unless the air of the room be made to contain at least five volumes 
per thousand of the gas, and this for a period of from four to six hours. 
The following method is the one generally employed. 

Take a large iron pot or caldron, put in it a little stand, such as the 
cheap tripod used by chemists, place on this an iron plate containing 
flowers of sulphur thoroughly wet with alcohol or (probably better 
still) with turpentine; underneath the plate set a tin alcohol lamp; 
then put the whole on bricks in the middle of the room. Light the 
lamp underneath the dish, and if the sulphur does not take fire pre¬ 
viously, when it begins actively to melt, ignite it. Leave the room 
at ODce, closing the door. The room must be as tight as possible, the 
chimney-places, ventilators, windows, and doors of exit being closed, 
while all the drawers of furniture and the doors of closets should be 
widely opened. 

Sulphurous acid may be used in a saturated solution for the purpose 
of destroying disease-germs in the excretions of the sick: * its action 
upon vegetable colors of course completely unfits it for many uses. 
The sulphites and the bisulphites are largely employed to arrest or 
control fermentation in various processes in the arts. 


* For a very interesting account, by Dr. J. Hjaltelin, of the strangling of a smallpox 
epidemic in Iceland, see British Medical Journal, 1871, vol. ii. p. 519. I cannot help be¬ 
lieving that the strict isolation and quarantining of the sick had far more to do with arresting 
the spread of the disease than had the sulphurous acid employed. 



APPENDIX 


WEIGHTS AND MEASURES OF THE UNITED STATES PHARMACOPEIA. 


Pound, 

lb 

= 

12 Ounces. 

Gallon, 

C = 

8 Pints. 

Ounce, 

l 

= 

8 Drachms. 

Pint, 

O = 

16 Fluidounces. 

Drachm, 

3 

= 

3 Scruples. 

Fluidounce, 

f S = 

8 Fluidrachms. 

Scruple, 

d 

= 

20 Grains. 

Fluidrachm, 

fa = 

60 Minims. 

Grain, 

g r - 

= 

1 Grain. 

Minim, 

m = 

1 Minim. 


WEIGHTS AND 


MEASURES OF THE METRICAL OR FRENCH SYSTEM. 


MEASURES OF LENGTH. 


One Myriametre 
One Kilometre 
One Hectometre 
One Decametre 
One METRE 
One Decimetre 
One Centimetre 
One Millimetre 


= 10,000 Metres. 

= 1,000 Metres. 

= 100 Metres. 

= 10 Metres. 

= the ten-millionth part of a quarter of the meridian of the earth. 
= the tenth part of one Metre, or 0.1 Metre. 

= the hundredth part of one Metre, or 0.01 Metre. 

= the thousandth part of one Metre, or 0.001 Metre. 


WEIGHTS. 


One Myriagramme = 
One Kilogramme = 
One Hectogramme = 
One Decagramme = 
One GRAMME = 
One Decigramme = 
One Centigramme = 
One Milligramme = 


10,000 Grammes. 

1,000 Grammes. 

100 Grammes. 

10 Grammes. 

the weight of a cubic Centimetre of Water at 4° C.. 
the tenth part of one Gramme, or 0.1 Gramme, 
the hundredth part of one Gramme, or 0.01 Gramme, 
the thousandth part of one Gramme, or 0.001 Gramme. 


One Myrialitre 
One Kilolitre 
One Hectolitre 
One Decalitre 
One LITRE 
One Decilitre 
One Centilitre 
One Millitre 

874 


MEASURES OF CAPACITY. 

= 10 cubic Metres, or the measure of 10 Milliers of Water. 

= 1 cubic Metre, or the measure of 1 Millier of Water. 

= 100 cubic Decimetres, or the measure of 1 Quintal of Water. 

= 10 cubic Decimetres, or the measure of 1 Myriagramme of Water. 
= 1 cubic Decimetre, or the measure of 1 Kilogramme of Water. 

= 100 cubic Centimetres, or the measure of 1 Hectogramme of Water. 
= 10 cubic Centimetres, or the measure of 1 Decagramme of Water. 
= 1 cubic Centimetre, or the measure of 1 Gramme of Water. 






APPENDIX. 


875 


RELATION OF WEIGHTS AND MEASURES OF THE U.S. PHARMACOPOEIA 

TO EACH OTHER. 


In diitilled water at the temperature of 60°. 


One 

Pound 

— 

0.7900031 Pint 


6067.2238 

Minims. 

One 

Ounce 

= 

1.0533376 Fluidounces 

= 

505.6019 

Minims. 

One 

Drachin 

= 

1.0533376 Fluidrachms 

= 

63.2002 

Minims. 

One 

Scruple 

= 


— 

21.0667 

Minims. 

One 

Grain 

= 


— 

1.0533 

Minims. 

One 

Gallon 

= 

10.1265427 Pounds 

T 

58328.8862 

Grains. 

One 

Pint 

= 

1.2658178 Pounds 

— 

7291.1107 

Grains. 

One 

Fluidounce 

= 

0.9493633 Ounce 

zzzz 

455.6944 

Grains. 

One 

Fluidrachm 

— 

0.9493633 Drachm 

— 

56.9618 

Grains. 

One 

Minim 



= 

0.9493 

Grain. 


RELATION OF MEASURES OF THE U.S. PHARMACOPOEIA TO CUBIC 

MEASURE. 

One Gallon = 231. Cubic Inches. One Fluidrachm = 0.22558 Cubic Inch. 

One Pint = 28.875 Cubic Inches. One Minim = 0.00375 Cubic Inch. 

One Fluidounce = 1.80468 Cubic Inches. 


RELATION OF WEIGHTS OF THE U.S. PHARMACOPOEIA TO METRICAL 

WEIGHTS. 


Fractions of a grain in 


Grain. 

Milligrammes. 

Milligrammes. 

ih 

= 

1.012 

eV 

== 

1.079 

3*0 

= 

1.295 

4*5 

= 

1.349 

ds 

= 

1.619 

& 

== 

1.799 

da 

= 

2.159 

5*3 

= 

2.591 


= 

2.699 

5 V 

= 

3.239 


= 

4.049 


= 

4.319 


= 

5.399 

At 

= 

6.479 

i 

= 

8.098 

i 

= 

10.798 

i 

= 

12.958 

i 

= 

16.197 

i 

= 

21.597 

i 

= 

32.395 


Grains in 

equivalent metrical 

Grains. 

1 

weights. 

Centigrammes. 
= 6.479 

2 

_ 

Decigrammes. 

1.295 

3 

— 

1.943 

4 

— 

2.591 

5 

— 

3.239 

6 

— 

3.887 

7 

= 

4.535 

8 

--- 

5.183 

9 

— 

5.831 

10 

— 

6.479 

12 

= 

7.775 

15 

= 

9.718 

16 

_ 

Grammes. 

1.036 

20 

= 

1.295 

24 

—; 

1.555 

25 

— 

1.619 

30 

== 

1.943 

40 

= 

2.591 

50 

— 

3.239 

60 

= 

3.887 


Drachms, Ounces, and Pounds in 
equivalent metrical weights. 


Drachms. 


Grammes. 

1 

—• 

3.887 

2 

= 

7.775 

3 

_ 

Decagrammes. 

1.166 

4 

= 

1.555 

5 

= 

1.943 

6 

== 

2.332 

7 

— 

2.721 

Ounces. 

1 

= 

3.1103 

2 

— 

6.2206 

3 

— 

9.3309 

4 

_ 

Hectogrammes. 

1.2441 

5 

-- 

1.5551 

6 

= 

1.8661 

7 

— 

2.1772 

8 

-- 

2.4882 

9 

= 

2.7992 

10 

= 

3.1103 

11 

= 

3.4213 

Pounds. 

1 

= 

3.7324 

2 

— 

7.4648 

3 

— 

Kilogrammes. 

1.1197 











876 


APPENDIX. 


RELATION OF METRICAL WEIGHTS TO WEIGHTS OF THE U.S. 

PHARMACOPEIA. 


Metrical 

Weights. 

Exact 
equivalents 
in grains. 

Approximate 
equivalents in 
grains. 

Milligrammes. 

1 = 

.0154 


o 

.0308 

'h 

3 = 

.0463 

2*2 

4 = 

.0617 

& 

5 = 

.0771 


6 

.0926 

A 

7 = 

.1080 

l 

9 

8 = 

.1234 

i 

9 = 

.1389 

* 

Centigrammes. 

1 = 

.1543 

* 

o 

.3086 

i 

3 = 

.4630 

A 

4 = 

.6173 

A 

5 = 

.7717 

i 

6 

.9260 

A 

7 = 

1.0803 

l 

8 = 

1.2347 

U 

9 = 

1.3890 

n 

Decigrammes. 

1 = 

1.543 

li 

2 = 

3.086 

3 

3 = 

4.630 

4* 

4 = 

6.173 

6 

5 = 

7.717 

7i 

6 = 

9.260 

9 

7 

10.803 

11 

8 = 

12.347 

12* 

9 = 

13.890 

14 


Metrical 

Weights. 

Exact 
equivalents 
in grains. 

Approximate 
equivalents in 
Troy Weight. 

Grammes. 



1 = 

15.434 

gr. xv. 

2 = 

30.868 

3ss. 

3 = 

46.302 

9>j- 

4 = 

61.736 

3i- 

5 == 

77.170 

9iv. 

6 = 

92.604 

3iss. 

7 = 

108.038 

l^vss. 

8 = 

123.472 

3ij- 

9 = 

138.906 

9 vi j- 

Decagrammes. 



1 = 

154.340 

3iiss. 

2 = 

308.680 

oy- 

3 = 

463.020 

gviiss. 

4 = 

617.360 

3*. 

5 = 

771.701 

Sxiij. 

6 = 

926.041 

3xv. 

7 = 

1,080.381 

Sxviij. 

8 = 

1,234.721 

3xx. 

9 = 

1,389.062 

3xxiij. 

Hectogrammes. 



1 = 

1,543.402 


2 = 

3,086.804 

3iy* 

3 = 

4,630.206 

§ix 3y- 

4 = 

6,173.609 

Ibi .^vij. 

5 = 

7,717,011 

Ibi §iv. 

6 = 

9,260.413 

Ibi gvij. 

7 = 

10,803.816 

Ibi 3iv. 

8 = 

12,347.218 

ftij & 3y • 

9 = 

13,890.620 

3 V - 

Kilogramme. 



1 = 

15,434.023 

Ibij ^viij. 

Myriagramme. 



1 = 

154,340.023 

f !b xxvi 

1 gix 5iv. 



APPENDIX. 


877 


TABLE OF THE 
GR. 0.825) 


PROPORTION BY MEASURE OF ALCOHOL (SP. 
CONTAINED IN ONE HUNDRED PARTS 
OF DIFFERENT WINES, ETC * 


Lisa (mean). 

25.41 

Teneriffe (C.). 

16.61 

Lunel. 

15.52 

Raisin wine (mean). 

25.12 

Colares. 

19.75 

Ditto (F.). 

18.10 

Marsala [Sicily ma- 


Lachryma Christi. 

19.70 

Shiraz. 

15.52 

deira] (mean). 

25.09 

White Constantia. 

19.75 

Ditto (C.). 

15.56 

strongest (J.). 

21.10 

Red Constantia. 

18.92 

Syracuse. 

15.28 

weakest (J.). 

19.90 

Lisbon. 

18.94 

Sauterne. 

14.22 

Port, strongest. 

25.83 

Ditto (C.). 

19.09 

Burgundy (mean). 

14.57 

mean. 

22.96 

Bucellas. 

18.49 

strongest (J.). 

13.20 

weakest. 

19.00 

Red madeira (mean)... 

20.35 

weakest (J.). 

10.10 

strongest (C.). 

20.49 

Cape muscat. 

18.25 

Hock (mean). 

12.08 

mean (C.). 

18.68 

Cape madeira (mean)... 

20.51 

strongest (J.). 

13.00 

weakest (C.). 

16.80 

Grape wine. 

18.11 

weakest (J.). 

9.50 

strongest (J.). 

23.20 

Calcavella (mean). 

18.65 

Nice. 

14.63 

weakest (J.). 

20.70 

Vidonia. 

19.25 

Barsac. 

13.86 

White port (C.) . 

17.22 

Alba flora. 

17.26 

Tent. 

13.30 

Madeira, strongest. 

24.42 

Zante. 

17.05 

Champagne (mean). 

12.61 

mean. 

22.27 

Malaga. 

17.26 

Ditto (F.). 

12.20 

weakest. 

19.24 

White hermitage. 

17.43 

Ditto, strongest (J.).... 

14.80 

strongest (C.). 

20.35 

Roussillon (mean). 

18.13 

weakest (J.). 

14.10 

strongest (J.). 

19.70 

Claret (strongest). 

17.11 

Red hermitage. 

12.32 

weakest (J.). 

19.00 

mean. 

15.10 

Yin de Grave (mean)... 

13.37 

Sercial madeira. 

21.40 

weakest. 

12.91 

Frontignac (Rives 


Ditto (C.). 

18.50 

ditto (F.). 

14.73 

Altes). 

12.79 

Sherry, strongest. 

19.81 

vin-ordinaire (C.). 

10.42 

Ditto (C.). 

12.29 

mean. ..... 

19.17 

Chateau-Latour, 


C6te rStie. 

12.32 

weakest. 

18.25 

1825 (C.). 

9.38 

Tokay. 

9.88 

strongest (C.). 

19.31 

first growth, 1811 


Rudesheimer, first 


mean (C.). 

18.47 

(C.). 

9.32 

quality (C.). 

10.14 

weakest (C.). 

16.96 

strongest (J.). 

11.10 

inferior (C.). 

8.35 

Amontillado (C.)... 

15.18 

weakest (J.). 

9.10 

Hambacher, first qua). 


strongest (J.). 

24.70 

Malmsey madeira. 

16.40 

(c.). 

8.88 

weakest (J.). 

15.40 

Ditto (C.). 

15.60 

Catawba (Stearns). 

Stoll 

Teneriffe . 

19.79 





Cider, highest average.. 

9.87 

Ale (Edinburgh). 

6.20 

Brandy. 

53.39 

lowest average. 

5.21 

Ale (Dorchester). 

5.56 

Rum. 

53.68 

Perry, average of four 


Brown stout. 

6.80 

Gin. 

51.60 

samples. 

7.26 

London porter. 

4.20 

Scotch whisky. 

54.32 

Mead. 

7.32 

London small beer. 

1.28 

Irish whisky. 

53.90 

Ale (Burton). 

8.88 






* The analyses whose results are given in this table were mostly made by Mr. Brande. 
When no mark is attached, the quotation is upon his authority. When the mark (F.) is 
added, the analysis was made by Julia-Fontenelle; (C.), by Professor Christison; (J.), by Dr. 
H. Bence Jones. 











































































































878 


APPENDIX. 



1, M. corrugator supercil.; 2, M. com¬ 
pressor nasi et pyramidal, nasi; 3, M. 
orbicular, palpebr.; 4, M. levator lab. 
sup. alseque nasi; 5, M. levator lab. sup. 
propr.; 6, M. zygomatic, minor; 7, M. 
dilatat. narium ant. et post.; 8, M. zygo¬ 
matic. major; 9, M. orbicularis oris; 
10, Ram. comm, pro Mm. triangular, 
et levator menti; 11, M. levator menti; 
12, M. quadratus menti; 13, M. triangu¬ 
laris menti; 14, Ram. subcutan. colli 
X. facial.; 15, Ram. cervical, pro Pla- 
tysmat.; 16, M. sterno-hyoideus; 17, M. 
omo-hyoideus; 18, M. sterno-thyroi- 
deus; 19, M. sterno-hyoideus; 20, M. 
frontalis; 21, Mm. a'ttrahens et at- 
tollens auriculae; 22, Mm. retrahens 
et attoll. auriculae; 23, M. occipitalis; 
24, Nerv. facialis; 25, Ram. auricular, 
post. prof. N. facialis; 26, M. stylo-hyoi- 
deus; 27, M. digastricus; 28, Ram. b’uc- 
cales, X. facialis; 29, M. splenius capi¬ 
tis; 30, Ram. subcutan. maxill. infer.; 
31, Ram. ext. X. accessorii Willisii; 32, 
M. sterno-cleido-mastoideus; 33, M. 
cucullaris; 34, M. sterno-cleido-mas¬ 
toideus; 35, M. levator anguli scap¬ 
ulae ; 36, X. thoracic, post. (Mm. rhom- 
boidei); 37, N. phrenicus; 38, M. omo¬ 
hyoid.;. 39, X. thoracic, lateral. (M. 
serrat. magn.); 40, X. axillaris; 41, 
Ram. plex. brachialis (X. musculo-cu- 
tan., pars X. mediani); 42, X. thoracic, 
ant. (M. pectorales). 


M. rectus ab¬ 
dominis. 
(Xervi intercos¬ 
tales abdomi- 
nales.) 



serratus mag- 
M. latissimus dorsi. 


M. obliquus ab¬ 
dominis exter- 
nus. 

(Nervi intercos¬ 
tales abdomi- 
nales.) 


M. transversus ab--- 
dominis. 

















































APPENDIX. 


879 


N. cruralis. 

N. obturatorius. 

M. sartorius. 

M. adductor longus. 

Rami N. cruralis pro M. quadrici- 
pite. 

M. cruralis. 

Rami N. cruralis pro M. vasto in- 
terno. 



M. tensor vaginae femoris. (Rami 
N. glutsei superioris.) 


M. tensor vaginae femoris. (Rami 
N. cruralis.) 


M. rectus femoris. 


M. vastus externus. 


M. vastus externus. 


M. peroneus longus. 
M. tibialis anticus. 


M. extensor hallucis longus... 


Rami N. peronei prof, pro M. 
extensore digitorum brevi 


Mm. interossei pedis dorsales. / 



N. peroneus. 

M. gastrocnemius externus. 

M. soleus. 

M. extensor digitorum longus. 


M. peroneus brevis. 
M. soleus. 


- M. flexor hallucis longus. 


M. extensor digitorum brevis. 


M. abductor dlgiti minimi 
pedis. 















880 


APPENDIX. 


Rami inferiores X. glutsei inferioris j|. 

pro M. glutseo mazimo —., _ 

X. ischiadicus.— 

M. biceps (caput longum).— 

M. biceps (caput breve). Wpl 

N. tibialis. - . W\ 

N. peroneus.-. "mBk 

M. gastrocnemius ezternus...' 'Wf 

M. soleus. 



M. adductor magnus. 
M. semitendinosus. 

M. semimembranosus. 


M. gastrocnemius internus. 


M. gastrocnemius internus. 
M. soleus.. 


M. flexor digitorum longus. 


N. tibialis. 



M. abductor hallucis 


















APPENDIX. 


881 


N. musculo-cutaneus. M. biceps. 



N. musculo- Caput in- N. media- N. ulnaris. Rami N. mediani 

cutaneus. ternus M. nus. M. brachialis pro M. pronatore 

tricipitis. interims. radii terete. 


Rami Nervi mediani pro M. pm 
natore radii terete 


M. palmaris longus 


M. ulnaris internus 


M. flexor digitorum sublimis 
(digitt. II et III.) 


N. ulnaris. 

M. flexor digitorum sublimis 
(digitt. indicis et minimi). 


Rami volar, prof. Nervi ulnaris.. 
M. palmaris brevis 


M. abductor digiti minimi 
M. flexor digiti minimi. 

M. opponens digiti minimi 


Mm. lumbricales II, III et IV 



M. radialis internus. 


M. flexor digitorum profundus. 


M. flexor digitorum sublimis. 


M. flexor pollicis longus. 

N. medianus. 


M. abductor pollicis brevis. 

M. opponens pollicis. 

M. flexor pollicis brevis. 

M adductor pollicis. 

M. lumbricalis I. 


56 






































a a 


882 


APPENDIX. 


Caput extemus M. trieipitis. 


N. radialis.-.. 

M. bracliialis intemus.. 

M. supinator longus-. 

M. radialis] extemus longus. 

M. radialis extemus brevis. 




. supinator longus.... 

. radialis externus longus. 


M. radialis externus brevis 


M. extensor digitorum communis 


M. extensor indicls proprius. 

M. extensor indieis proprius et M. 

abductor pollicis longus. 

M. abductor pollicis longus. 


M. extensor pollicis brevis. 

M. flexor pollicis longus. 


M. interosseus dorsalis I. 

M. interosseus dorsalis II.. 

M. interosseus dorsalis III. 


M. ulnaris externus. 


M. extensor digiti minimi pro¬ 
prius. 


M. extensor indieis proprius. 
M. extensor pollicis longus. 


M. abductor digiti minimi. 
M. interosseus dorsalis IV. 
























GENERAL INDEX 


A. 

Abies Canadensis, 814. 
excelsa, 814. 
picea, 814. 

Absorbents, 857. 

Abstract of aconite, 418. 
of belladonna, 231. 
of conium, 325. 
of digitalis, 363. 
of ignatia, 270. 
of jalapa, 697. 
of nux vomica, 253. 
of senega, 768. 

Abstracta, 99. 

Acacia, 821. 
vera, 821. 

Aceta, 100. 

Acetate of ammonium, 756. 
of copper, 463. 
of lead, 456, 762. 
of morphine, 171. 
of potassium, 720. 
of sodium, 841. 
of zinc, 460. 

Acetated tincture of opium, 
171. 

Acetic acid, 433. 

Acetphenetidin, 635. 

Acetophenone, 196. 

Acetum, 433. 
lobeliae, 310. 
opii, 170. 
sanguinariae, 660. 
scillse, 710. 

Acid, benzoic, 771. 
carbazotic, 592. 
cathartic, 692. 
copaivic, 737. 
cubebic, 739. 
gentisic, 638. 
hydrobromic, 297. 
meconic, 179. 
picric, 592. 
salicylic, 613. 

Acidum aceticum, 433. 

aceticum dilutum, 433. 
aceticum glaeiale, 433. 
arseniosum, 498, 817. 
benzoicum, 771. 
boricum, 870. 
carbolicum, 593, 866. 
earbolicum crudum, 593. 
chromicum, 820. 
citricum, 432. 
gallicum, 440. 


Acidum hydrobromicum dilu¬ 
tum, 482. 

hydrochloricum, 482. 
hydrochloricum dilutum, 
482. 

hydrocyanicura, 419. 
hydrocyanicum dilutum, 
419. 

lacticum, 4S6. 
muriaticum, 482, 820. 
muriaticum dilutum, 
482. 

nitricum, 482, 819. 
nitricum dilutum, 484. 
nitro-hydrochlorieum, 
484. 

nitro-muriaticum, 484. 
nitro-muriaticum dilu¬ 
tum, 484. 
nitrosum, 483. 
oxalicum, 434. 
phosphoricum dilutum, 
548. 

picrurn, 592. 
salicylicum, 611. 
sulphuricum, 479, 819. 
sulphuricum aromati- 
cum, 482. 

sulphuricum dilutum, 
481. 

sulphurosum, 872. 
tannicum, 438. 
tartaricum, 430. 
valerianicum, 117. 
Aconelline, 408. 

Aconite as a diaphoretic, 749. 
leaves, 407. 
root, 407. 

Aconitine, 408. 

crystallized, 408. 
Aconitum, 407. 

antidote for, 418. 

Adeps, 826. 

benzoinatus, 774. 
Adhesive plaster, 454, 733. 
Administration, methods of, 
102 . 

Adonidine, 382. 

Adonis vemalis, 382. 

ASther, 137. 

fortior, 137. 

African pepper, 646. 

Age in relation to dose, 106. 
Alcohol, 331. 

as a sudorific, 758. 
dilutum, 331. 


Alcohol fortius, 331. 

Alexandria senna, 692. 

Alimentation, rectal, 35. 

Allium, 775. 

Allspice, 645. 

Aloe, 671, 689, 778. 
Barbadensis, 689. 
Capensis, 689. 
purificata, 691. 
Socotrina, 689. 

Aloin, 689. 

Alterative diuretics, 728. 

Alteratives, 113, 763. 

Althaea, 824. 

officinalis, 824. 

Alum, 444. 

as an emetic, 665. 
curd, 444. 

Alumen, 444. 

exsiceatum, 444. 

Aluminae sulphas, 445. 

Amber, 122. 

American hellebore, 392. 
hemp, 197. 

Ammonia, 327, 814. 

Ammonia alum, 444. 

Ammoniac, 76S. 
mixture, 769. 
plaster, 769. 

Ammoniacum, 768. 

Ammoniated copper, 462. 
mercury, 528. 
tincture of guaiac, 560. 
tincture of valerian, 117 

Ammonii acetas, 756. 
bromidum, 294. 
carbonas, 331. 
chloridum, 763. 
nitras, 331. 
sulphas, 331. 
valerianas, 117. 

Ammonio-eitrate of bismuth 
456. 

Ammonio-ferric alum, 475 
479. 

Amorphous hyoscyamine 
234. 

Amygdalin, 642. 

Amyl, nitrite of, 298. 
valerianate of, 309. 

Amylene hydrate, 194. 

Amyli nitritum, 298. 

Amylic alcohol, 331. 

Anacyclus pyrethrum, 801. 

Anaesthetics, 112, 128. 

Anelectronus, 83. 

883 





884 

Animal charcoal, 857. 

Anise, 648. 

water, 648. ^ 

Anisum, 648. 

Anodes, 70. 

Antacids, 837. 

Anthelmintics, 844. 
Anthemis, 649. 

ADtifebrin, 630. 
Antihydropin, 713. 
Antimonial ointment, 391. 
plaster, 391. 
wine, 391. 

Antimonii et potassii tartras, 

385. 

oxidutn, 385. 
sulphidum, 385. 

puriticatum, 385. 
sulphuretum, 385. 
Antimony, 385. 
Antiperiodics, 113. 
Antipyretics, 113. 

Antipyrin, 625. 

Antiseptics, 859. 
Antispasmodics, 112, 114. 
Apiin, 780. 

Apiol, 780. 

Apomorphine, 660. 

Aqua ammonise, 331, 814. 
ammonite fortior, 331, 
814. 

aurantii florum, 648. 
camphorte, 121. 
chlori, 867. 
cinnamomi, 644. 
foenieuli, 648. 
mentha piperita, 648. 

viridis, 648. 
rosmarini, 648. 

Aquae, 100. 

Arabin, 821. 

Araroba, 685. 

Arbutin, 729. 

Argel, 692. 

Argenti cyanidum, 429, 471. 
iodidum, 471. 
nitras, 463. 
nitras dilutus, 471. 
nitras fusus, 464. 
oxidum, 471. 

Argentum, 463. 

Argol, 430. 

Arnica flowers, 406. 

root, 406. 

Arnicine, 406. 

Aromatic bitters, 649. 
powder, 644. 
spirit of ammonia, 331. 
spirit of hartshorn, 838. 
sulphuric acid, 482. 
syrup of rhubarb, 688. 
tincture of rhubarb, 688. 
Aromatics, 643. 

Arrow-root, 825. 
porridge, 32. 

Arseniate of sodium, 513, 563. 
Arsenic, 498, 817. 

antidotes for, 512. 
as a caustic, 511, 817. 
Arsenic-eating, 504. 
Arsenical paper, compound, 
510. 

paste, 818. 


GENERAL INDEX. 

Arsenici iodidum, 513. 
Arsenious acid, 498, 817. 

ointment, 817. 

Arsenite of potassium, 513. 
Art of prescribing medicines, 
107. 

Artemisia Contra, 846. 
Artificial camphor, 733. 
Artificially digested foods, 33. 
Asafetida, 117. 
mixture, 118. 
suppositories, 118. 
Asafoetida, 117. 

Asiatic pill, 509. 

Aspic, 648. 

Aspidium, 851. 

Astley Cooper’s arsenious 
paste, 817. 

Astragalus verus, 822. 
Astringents, 112, 436, 762. 
mineral, 444. 
vegetable, 436. 
Atomization, 104, 760. 
Atropinse sulphas, 231. 
Atrojnne, 202. 

antagonism to Calabar 
bean, 283. 

antagonism to jaborandi, 
755. 

poisoning by, 229. 
Aurantii arnari cortex, 646. 
dulcis cortex, 646. 
flores, 646. 

Azedarach, 845. 

B. 

Bacillus-spores, killingof, 862. 
Baked meal porridge, 32. 
Balm, 64S. 

Balsam of Peru, 774. 
of Tolu, 774. 

Balsamum Peruvianum, 774. 
Tolutanum, 774. 
traumaticum, 774. 

Banks oil, 542. 

Bantingism, 44. 

Barbadoes aloes, 6S9. 
Barbaloin, 689. 

Barberry, 640. 

Bark of pomegranate root, 
851. 

Barley, 825. 

water, 825. 

Barytine, 399. 

Bassorin, 822. 

Baths, cold, 58. 
hot, 669, 743. 

Turkish, 743. 
vapor, 743. 

Bean of St. Ignatius, 270. 
Bearberry, 729. 

Bebeerine, 638. 

sulphate, 638. 

Bebeeru bark, 638. 

Beef essence, 29. 
tea, 29. 

Belladonna in opium-poison¬ 
ing, 166. 
leaves, 222. 
plaster, 222. 
root, 222. 

Belladonna; folium, 222. 


Belladonnae radix, 222. 

Benzoic acid, 771. 

Benzoin, 771. 

Benzoinum, 771. 

Berberine, 639. 

Bethol, 624. 

Bicarbonate of potassium, 719. 
of sodium, 841. 

Bichloride of mercury, 526. 
of methylene, 153. 

Biniodide of mercury, 527. 

Bismuth, 456. 

Bismuthi citras, 458. 

et ammonii citras, 457. 
subcarbonas, 456. 
subnitras, 456. 

Bismuthum, 456. 

Bisulphate of quinine, 585. 

Bitartrate of potassium, 721. 

Bitter orange peel, 646. 

Bitters, 171. 
simple, 637. 

Black draught, 693. 
drop, 171. 
ginger, 645. 
hellebore, 705, 779. 
mustard, 812. 
oak, 443. 
oil, 542. 

oxide of manganese, 479. 
pepper, 645. 
snakeroot, 703. 
wash, 528. 

Blatta oriental is, 713. 

Blattic acid, 713. 

Bleaching powder, 869. 

Blistering cerate, 810. 

Blisters, 806. 

Bloodroot, 659. 

Blue galls, 439. 
mass, 523, 684. 
ointment, 523. 
pills, 523, 684. 

Bluestone, 461. 

Boneblack, 857. 

Boneset, 641. 

Bonwill’s method of anaes¬ 
thesia, 129. 

Boracic acid, 870. 

Borax, 870. 

Boric acid, 870. 

Bougies, 104. 

Bran, 677. 

Brandy, 331. 

Brayera, 846. 

anthelmintiea, 846. 

Brazilian sarsaparilla, 560. 

Bread and milk, 833. 

Bromal hydrate, 298. 

Bromated camphor, 121. 

Bromcamphor, 121. 

Bromide of'ammonium, 294. 
of camphor, 121. 
of ethyl, 153. 
of iron, 479. 
of lithium, 296. 
of nickel, 296. 
of potassium, 285. 
of sodium, 296. 

Brominated camphor, 121. 

Bromine, 820, 868. 

Bromoform, 153. 

Bromum, 820. 




GENERAL INDEX. 


885 


Broom, 712. 

Broth, chicken, 29. 

Brown mixture, 824. 

• oil, 542. 
sugar, 677. 

Brucine, 269. 

Buchu, 728. 

Buckthorn, 678. 

Burgundy pitch, 814. 
pitch plaster, 814. 

Burnt alum, 445, 820. 

Butternut, 6S9. 

Butyl chloral hydrate, 192. 

Buxine, 638. 

C. 

Cacao butter, 826. 

Cadmii sulphas, 460. 

Cadmium, 460. 

Caffea, 364. 

Caffeine, 364, 713. 

Calabar bean, 271. 

Calabarina, 271. 

Calabarinum purum, 271, 
note. 

Calamine, 460. 

Calamus, 648. 

Calcii carbonas prmcipitatus, 
843. 

Calcii phosphas pnecipitatus, 
548. 

California buckthorn, 679. 

Calisaya bark, 563. 

Calomel, 523. 

as a purge, 684. 

Caloric, 55. 

Calumba, 641. 

Calx, 841. 

ehlorata, 868. 
sulphurata, 682. 

Camboge, 517. 

Camphor, 118. 
artificial, 733. 
bromated, 121. 
carbolated, 122. 
mixture, Hope’s, 484. 
monobromate of, 121. 
oil, 121. 
water, 121, 

Camphora, 118. 

Camphorated tincture of 
opium, 171. 

Camphor-cymol, 119. 

Canada balsam, 732. 
erigeron, 731. 
fleabane, 731. 
pitch, 814. 
pitch plaster, 814. 
turpentine, 732. 

Cannabin, 197. 

Cannabis Americana, 197. 
Indica, 197. 

Canquoin’s paste, 818. 

Cantharidal collodion, 810. 

Cantharides, 782, 807. 
cerate, 810. 
paper, 810. 

Cantharidin, 807. 

Cantharis, 742. 

Cape aloes, 689. 

Capsicin, 646, 813. 

Capsicum, 646, 813. 


Caraway, 648. 

Carbazotate of ammonium, 
593. 

Carbazotic acid, 592. 

Carbo, 857. 

animalis, 857. 

purificatus, 857. 
ligni, 857. 

Carbolated camphor, 122. 

Carbolic acid, 594. 
antidote to, 602. 
as a disinfectant, 866. 
as an antiseptic, 606. 
parenchymatous injec¬ 
tions of, 602. 
poisoning, 605. 

Carbonate of ammonium, 
331. 

of calcium, 843. 
of lead, 456. 
of lithium, 727. 
of magnesium, 679. 
of potassium, 719. 
of sodium, 837. 
of zinc, 460. 

Cardamom, 645. 

Cardamomum, 645. 

Cardiac depressants, 384. 
stimulants, 112. 

Cardiants, 112. 

Carminatives, 643. 

Carolina jessamine, 311. 

Carrageen, 823. 

Carrageen in, 823. 

Carron oil, 842. 

Carthagena bark, 563. 

Carum, 648. 

Caryophyllus, 644. 

Cascara Sagrada, 679. 

Cascarilla, 649. 

Cassava, 824. 

Cassia bark, 644. 

Fistula, 678. 

Castillon’s powder, 843. 

Castor, 115. 
oil, 682. 
oil beans, 682. 

Castoreum, 115. 

Catechu, 441. 

Cathartic acid, 692. 

Cathartics, 666. 

Cathartin, 692. 

Cathode, 70. 

Caustic potash, 816. 
lime, 842. 
soda, 840. 

Cayenne pepper, 646. 

Central galvanization, 97. 

Cera alba, 62, 826. 
flava, 62, 826. 

Cerata, 101. 

Cerates, 101. 

Ceratum cantharidis, 810. 
extracti cantharidis, 810. 

Cerebrum, galvanization of 
the, 94. 

Cerii oxalas, 459. 

Cetaceum, 826. 

Cetraria, 822. 

islandica, 822. 

Cetraric acid, 822. 

Cetrarin, 822. 

Chalk, 843. 


Chalk mixture, 843. 
Chamomile, 649, 

Champagne, 345. 

Charcoal, 857. 
poultiees, 857. 

Charta arsenicalis composita, 
510. 

cantharidis, 810. 
sinapis, 813. 

Chartse, 101. 

Chelerythrin, 659. 

Chemical current, 78. 

food, 550. 

Chenopodium, 845. 

anthelminticum, 846. 
Chian turpentine, 736. 
Chicken broth, 29. 

Children, couqiarative dose 
for, 106. 

Chili saltpetre, 722. 
Chimaphila, 730. 
Chimaphilin, 730. 

Chinoidin, 588. 

Chinoidinuin, 588. 

Chirata, 641. 

Chloral, 179. 

alcoholate, 180. 
camphor, 192. 
hydrate, 180. 
poisoning, 189. 

Chlorate of potassium, 724. 

of sodium, 726. 

Chloride of ammonium, 765. 
of iron, 477. 

of mercury, corrosive, 
526. 

of mercury, mild, 523. 
of potassium, 523. 
of zinc, 818. 

Chlorinated lime, 868. 
Chlorine, 867. 

water, 867. 

Chloroform, 143. 

Chloroformum purificatum, 
143. 

venale, 143. 

Chlorum, 867. 

Chocolate porridge, 33. 
Cholagogues, 666. 

Chondrus, 823. 

Chondrus crispus, 823. 
Chromic acid, 820. 

Chrysaroba, 687. 

Chrysophanic acid, 687. 
Churrus, 197. 

Cigarettes, arsenical, 510. 
Cimicifuga, 125. 

Cinchona, 563. 
flava, 563. 
pale, 563. 
pallida, 563. 
red, 563. 
rubra, 563. 
yellow, 563. 
Cinchonamine, 588. 
Cinchonidine, 586. 

Cinchoninse sulphas, 586. 
Cinchonine, 586. 

sulphate of, 586. 

Cinnamic acid, 774. 

Cinnamon, 644. 
water, 644. 

Citrate of bismuth, 458. 









886 


GENERAL INDEX. 


Citrate of bismuth and ammo¬ 
nium, 458. 
of caffeine, 374. 
of iron, 478. 

of iron and ammonium, 
478. 

of iron and quinine, 
478. 

of iron and strychnine, 
478. 

of lithium, 727. 
of magnesium, 694. 
of potassium, 720, 749. 
Citric acid, 432. 

Clarke’s Rule for Doses, 106. 
Classification, 111. 

Claviceps purpurea, 784. 
Climate, 105. 

Cloves, 644. 

Clove-tea, 644. 

Coca, 239. 

Cocaine, 239. 

Coca-tannic acid, 239. 
Cockroach, 713. 

Codeine, 174. 

Cod-liver oil, 542. 

Coffee, 364. 

Cohnheim’s salt frog, 184. 
Cola nut, 365. 

Colchiceine, 551. 

Colchici radix, 551. 

semen, 551. 

Colchicine, 551. 

Colchicum root, 551. 

seed, 551. 

Cold as a tonic, 58. 
in pyrexia, 58. 
local use of, 56. 

Cold cream, S26. 

Collodion, 835. 

with cantharides, 810. 
Collodium, 835. 

cum cantharide, 810. 
flexile, 836. 

Colocynth, 697. 

Colocynthin, 697. 

Colocynthis, 697. 

Columbin, 641. 

Columbo, 641. 

Commercial bicarbonate of 
sodium, 841. 
chloroform, 143. 
oxide of zinc, 460. 
Compound arsenical paper, 
510. 

cathartic pills, 698. 
decoction of sarsaparilla, 
559. 

extract of colocynth, 698. 
fluid extract of sarsapa- 
‘ rilla, 559. 

infusion of flaxseed, 824. 
infusion of gentian, 640. 
infusion of rose, 443. 
infusion of senna, 693. 
iodine ointment, 534. 
jalap powder, 696. 
liquorice powder, 693, 
824. 

mixture of iron, 476. 
mixture of liquorice, 824. 
pills of iron, 476. 
pills of rhubarb, 688. 


Compound powder of ipecacu¬ 
anha, 748. 

powder of jalap, 696. 
powder of rhubarb, 688. 
solution of iodine, 534. 
spirit of ether, 123. 
spirit of juniper, 731. 
spirit of lavender, 648. 
syrup of sarsaparilla, 
559. 

syrup of squill, 775. 
syrup of the phosphates, 
550. 

tincture of benzoin, 774. 
tincture of cardamom, 
643. 

tincture of catechu, 442. 
tincture of cinchona, 588. 
tincture of gentian, 638. 
tincture of iodine, 534. 
Confection of rose, 443. 

of senna, 693. 
Confectiones, 101. 

Confections, 101. 

Conii folia, 320. 

fructus, 320. 

Conine, 320. 

Conium, 320. 

Consomme soup, 30. 
Continuous current, 78. 
Convallamarin, 374. 
Convallaria majalis, 374. 
Convallarin, 374. 

Cooper’s arsenious ointment, 
817. 

Copaiba, 737. 

Copaivie acid, 737. 

Copper, 461. 

Copperas, 864. 

Coriander, 648. 

Coriandrum, 648. 

Corrosive chloride of mercury, 
526. 

sublimate, 526, 819, 865. 
as a caustic, 819. 
Corsican moss, 823. 
Cosmoline, 831. 

Cotton-root, 799. 
Counter-irritation, 803. 
Cowhage, 852. 

Cowling’s Rule for Doses, 106. 
Coxe’s hive syrup, 775. 
Cracked wheat, 677. 
Cranesbill, 443. 

Cream of tartar, 721. 
Creasote, 606. 

Creasotum, 606. 

Creta, 843. 

praeparata, 843. 

Croton chloral hydrate, 193. 
Croton oil, 667, 671, 704. 
Crotonol, 704. 

Crvptopine, 178. 

Cubeb, 739, 801, 802. 

Cubeba, 739. 

Cubebic acid, 739. 

Cubebin, 739. 

Cupri acetas, 463. 

sulphas, 461. 

Cuprum, 461. 

ammoniatum, 463. 
Cyanide of potassium, 429. 
of silver, 429, 471. 


Cyano-haemoglobin, 422. 
Cyanogen gas, 429. 
Cydonium, 824. 

Cytisin, 406. 


D. 

Dandelion, 561. 

Daphnin, 561. 

Daturine, 232. 

Decocta, 99. 

Decoction of barley, 825. 
Decoctum chimaphilae, 730. 
hordei, 825. 

sarsaparillae composi- 
tum, 559. 

Degeneration, reaction of, 88. 
Delirifacients, 112, 197. 
Demulcents, 821. 
Dcnarcotized opium, 170. 
Deodorized tincture of opium, 
170. 

Depresso-motors, 112. 
Dewees’s emmenagogue mix¬ 
ture, 782. 

Dextro-quinine, 586. 
Diagnosis, use of electricity 
in, 87. 

Dialyzed iron, 478. 
Diaphoretics, 743. 

Diastase, 855. 

Diet in corpulence, 46. 
in lithiasis, 51. 
in rest-cure, 41. 
Digestants, 853. 

Digested foods, 33. 

Digitalein, 346. 

Digitalin, 346, 364. 
Digitalinum, 346, 364. 
Digitaliresin, 346. 

Digitalis, 346. 

as a diuretic, 710. 
as an antipyretic, 360. 
Digitonin, 347. 

Digitoxin, 347. 

Digitoxiresin, 348. 
Dihydroxyle quinine, 577, 
note. 

Diluents, 762, 834. 

Diluted acetic acid, 433. 
alcohol, 331. 
hydrobromic acid, 297. 
hydrochloric acid, 482. 
hydrocyanic acid, 419. 
muriatic acid, 482. 
nitric acid, 484. 
nitro-muriatic acid, 485. 
phosphoric acid, 548. 
solution of subacetate of 
lead, 455. 

sulphuric acid, 481. 
Disease, 105. 

Disinfectants, 859. 

Diuretics, 706. 

Donovan’s solution, 536. 
Doses, rules for, 106. 

Dover’s powder, 748. 

Drastics, 695. 

Dried alum, 444. 

carbonate of sodium, 841. 
sulphate of iron, 476. 
Drugs, 99. 






GENERAL INDEX. 


E. 

Ecboline, 785. 

Effects of medicines, primary, 
101 . 

remote, 101. 
secondary, 101. 
Effervescing draught, 720, 
749. 

Eggnog, 31, 346. 

Elaterin, 700. 

Elaterium, 700. 

Electric brush, 94. 
Electricity, 72. 

use of, as a tonic, 94. 
Elixir of valerianate of am¬ 
monium, 117. 
of vitriol, 482. 
Proprietatis, 691. 
Emetics, 650. 
mineral, 665. 
vegetable, 654. 

Emetine, 654. 
Emmenagogues, 778. 

Emodin, 679. 

Emollients, 826. 

Emplastra, 101. 

Emplastrum ammoniaci, 769. 
ammoniaci cum hydrar- 
gyro, 769. 
antimonii, 391. 
asafcetid®, 118. 
belladonnas, 231. 
hydrargyri, 523. 
picis Burgundicse, 814. 
picis Canadensis, 814. 
picis cum cantharide, 
814. 

plumbi, 454, 835. 
resin®, 454, 733, 835. 
saponis, 455, 835. 
Emulsin, 642, 812. 

Emulsions, 100. 

Endermic administration, 
104. 

Enemata, 673. 

nutritive, 35. 

English aconitine, 408. 

garlic, 775. 

Epispastics, 803, 806. 

Epsom salt, 693. 

Ergot, 784. 

Ergota, 784. 

Ergotic acid, 785. 

Ergotin, 785, 798. 

Ergotinin, 785. 

Ergotism, 796. 

Erigeron, 731. 

Canadense, 731. 

Errhines, 802. 

Erythroxyline, 239. 
Erythroxylon, 239. 
Escharotics, 815. 

Eserine, 271. 

Essence of beef, 29. 

of peppermint, 648. 
of spearmint, 648. 
Essential salt of lemons, 434. 
Ether, 137. 

Ethereal bromide, 153. 
oil, 123. 

Ethyl, lead, 453. 
nitrite of, 309. 


Ethyl oxide, 137. 

Eucalypsinthe, 589, note. 

Eucalyptus, 589, 776. 

Euonymin, 679. 

Euonymus, 679. 

Eupatorium, 641. 

Excito-motors, 112. 

Expectorants, 759. 

Extract of aconite, 418. 

of American hemp, 197. 
of arnica, 407. 
of belladonna, 230. 
of black hellebore, 705. 
of butternut, 689. 
of Calabar bean, 282. 
of chirata, 641. 
of cinchona, 5S8. 
of colekicum root, 558. 
of colocynth, 698. 
of conium, 325. 
of dandelion, 561. 
of digitalis, 363. 
of ergot, 799. 
of euonymus, 679. 
of gentian, 640. 
of hmmatoxylon, 442. 
of hellebore, 705. 
of hyoscyamus, 235. 
of ignatia, 270. 
of Indian hemp, 197. 
of juglans, 689. 
of krameria, 442. 
of liquorice, 824. 
of logwood, 442. 
of malt, 855. 
of May-apple, 700. 
of nux vomica, 253. 
of opium, 171. 
of podophyllum, 700. 
of quassia, 637. 
of rhatany, 442. 
of rhubarb, 688. 
of stramonium, 233. 
of taraxacum, 561. 
of uva ursi, 730. 
of wahoo, 679. 

Extracta, 101. 
fluida, 101. 

Extractum cannabis Indiem, 
197. 

juglandis, 689. 
malti, 855. 

Extraneous remedies, 112, 
837. 

F. 

Faradic current, 80. 

Faradization, general, 97. 

Feeding of the sick, 26. 
by the rectum, 33. 

Fennel, 648. 
water, 648. 

Ferri bromidum, 479. 
carbonas, 475. 
carbonas saccharatus, 
476. 

chloridum, 477. 
citras, 477. 

et ammonii citras, 478. 
et ammonii sulphas, 479. 
et ammonii tartras, 478. 
et potassii tartras, 478. 
et quinin® citras, 478. 


887 

Ferri et strychnin® citras, 
478. 

lactas, 478. 

oxidum hydratum, 475. 
oxidum hydratum cum 
magnesia, 475, 512. 
phosphas, 479. 
pul vis, 475. 
pyrophosphas, 479. 
sulphas, 476. 
sulphas exsiccatus, 476. 
sulphas praecipitatus, 
476. 

Ferrum, 472. 

dialysatum, 478. 
reductum, 475. 

Ficus, 677. 

Figs, 677. 

Filix Mas, 851. 

Flaxseed, 824. 
meal, 833. 
oil, 824. 

Fleabane, 731. 

Fleming’s tincture of aconite, 
418. 

Flexible collodion, 836. 

Flowers of sulphur, 680. 

Fluid extract of aconite root, 
418. 

of American hellebore, 

398. 

of arnica, 407. 
of belladonna, 230. 
of bitter orange peel, 647. 
of boneset, 641. 
of brayera, 846. 
of buchu, 728. 
of cannabis Indica, 202. 
of chimaphila, 730. 
of chirata, 641. 
of cimicifuga, 126. 
of coca, 251. 
of colchicum root, 552. 
of colchicum seeds, 552. 
of columbo, 641. 
of conium, 325. 
of cotton root, 799. 
of cubebs, 741. 
of dandelion, 561. 
of digitalis, 363. 
of ergot, 798. 
of eupatorium, 641. 
of gelsemium, 314. 
of gentian,- 638. 
of ginger, 645. 
of gossypi radieis cortex, 
799. 

of grindelia, 765. 
of hemp, 202. 
of hops, 125. 
of ipecacuanha, 659. 
of jaborandi, 755. 
of krameria, 443. 
of lactucarium, 125. 
of liquorice, 824. 
of lobelia, 311. 
of lupulin, 125. 
of matico, 741. 
of nux vomica, 253. 
of pareira brava, 729. 
of quassia, 639. 
of rhatany, 443. 
of rhubarb, 6S8. 








888 


GENERAL INDEX. 


Fluid extract of rhus glabra, 
443. 

of rose, 443. 
of sanguinaria, 660. 
of sarsaparilla, 559. 
of senega, 768. 
of senna, 693. 
of serpentaria, 649. 
of spigelia, 845. 
of spigelia and senna, 
845. 

of squill, 710. 
of stramonium, 233. 
of sumach, 443. 
of taraxacum, 561. 
of uva ursi, 730. 
of valerian, 116. 
of veratrum viride, 398. 
of wild cherry, 643. 
Foeniculum, 648. 

Foods, artificially digested, 
33. 

liquid meat, 27. 
milk, 30. 

Foot-bath, method for, 758. 
Forced injections, 673. 
Fowler’s solution, 513. 
Frangula, 678. 

Franguline, 678. 

Frere Cosme, arsenical paste 
of, 817. 

Fumigations, mercurial, 522. 
Fusel oil, 331. 

G. 

Gaduin, 543. 

Galactagogue, 683. 

Galla, 439. 

Gallic acid, 441. 

Gallo-tannic acid, 438. 

Galls, 441. 

Galvanic current, 78. 

Gambir, 442. 

Gamboge, 702. 

Gambogia, 702. 

Gambogic acid, 703. 

Garlic, 775. 

Gas liquor, 765. 

Gaultheria, 622. 

Gelsemine, 311. 

Gelseminic acid, 311. 
Gelsemium, 311. 

General faradization, 97. 
Gentian, 637. 

Gentiana, 637. 

Gentiopikrin, 638. 

Gcntisic acid, 638. 

Geranium, 443. 

German aconitine, 408. 

chamomile, 649. 
Germicide, 859. 

Gin, 731. 

Ginger, 645. 

Gizzard, 855. 

Glacial acetic acid, 433. 
Glauber salt, 694. 

Glycerin, 827. 

Glycerinum, 827. 

Glycerita, 100. 

Glycerite of egg, 830. 

of starch, 830. 
Glyceritum amyli, 830. 


Glyceritum vitelli, 830. 
Glycyrrhiza, 823. 

glabra, 823. 

Glycyrrhizin, 823. 
Glycyrrhizinum ammonia- 
turn, 824. 

Goa powder, 687. 

Golden seal, 639. 
Goose-grease, 826. 

Gossypii radicis cortex, 799. 
Goulard’s extract, 455. 
Granatum, 851. 

Granulated citrate of magne¬ 
sium, 694. 

Gray powder, 523. 

Green galls, 439. 
ginger, 645. 
iodide of mercury, 527. 
Grindelia, 764. 

robusta, 764. 

Guaiac, 559, 782. 
acid, 560. 

as an emmenagogue, 782. 
yellow, 560. 

Guaiaci lignum, 559. 

resina, 559. 

Guaiacic acid, 560. 

Guaiacin, 560. 

Guaiaconic acid, 560. 
Guaiacresinic acid, 560. 
Guaiacum wood, 559. 
Guarana, 364. 

Gum arabic, 821. 

Gun-cotton, 835. 

Gunjah, 197. 

Gutta-percha, 836. 


H. 


Habit, 105. 

Hasmatin, 442. 

Hmmatoxylin, 442. 
Hmmatoxylon, 442. 
Hartshorn, spirit of, 331. 
Hashish, 197. 

Heat, 55. 

Heavy magnesia, 679. 

oil of wine, 123. 
Helleboreine, 705. 
Helleborine, 705. 

Helleborus, 705. 

Hemlock pitch, 814. 

plaster, 814. 

Hemp, 197. 

Herapathite, 564. 

Hippuric acid, 772. 

Hive syrup, 775. 

Hoffmann’s anodyne, 123. 
Homatropine, 231. 

Honduras sarsaparilla, 558. 
Honey, 100. 

Hop poultice, 125. 

Hope’s camphor mixture, 
484. 

Hops, 124. 

Hordeum, 825. 

Hot baths, 744. 

Humulus, 124. 

Huxham’s tincture, 588. 
Hydragogue diuretics, 708. 
Hydragogues, 675. 
Hydrargyrum, 513, 684. 
ammoniatum, 528. 


Hydrargyrum chloridum cor- 
rosivum, 526, 819. 
chloridum mite, 523. 
cum creta, 523. 
iodidum rubrum, 527. 
iodidutn viride, 527. 
oleatum, 523. 
oxidum flavuin, 527. 
oxidum rubrum, 527. 
sulphas flavus, 628. 
sulphidum rubrum, 528. 

Hydrastin, 640. 

Hydrastine, 641. 

Hydrastis, 639. 

Canadensis, 639. 

Hydrate of amylene, 194. 
of chloral, 179. 

Hydrated oxide of iron, 475. 
sesquioxide of iron, 475. 

Hydriodate of hyoscine, 236. 

Hydrobromate of conine, 326. 
of homatropine, 231. 
of hyoscine, 236. 
of quinine, 585. 

Hydrobromic acid, 299. 

Hydrochinone, 729. 

Hydrochlorate of apomor- 
phine, 660. 
of morphine, 171. 
of pilocarpine, 755. 

Hydrochloric acid, 482. 

Hydrocotarnine, 179. 

Hydrocyanic acid, 419. 

Hyoscine, 236. 

Hvoscyami folia, 234. 

Hyoscyamine, 234. 

Ilyoscyamin® sulphas, 234. 

Hyoscyamus leaves, 234. 

Hyperemesis, 653. 

Hypnone, 196. 

Hypochlorites, 868. 

Hypodermic injections, 103. 
injections of calomel, 524. 

I. 

Iceland moss, 822. 

Ichthyol, 561. 

Idiosyncrasies, 105. 

Igasuric acid, 253. 

Ignatia ainara, 270. 

Ignatine, 270. 

Ilex, 364. 

Incompatibilities, 110. 

Indian corn, 732. 

Indian hemp, 197. 

Indian meal, 677, 833. 
smut of, 799. 
stigmata of, 732. 

Indian senna, 692. 

Indications for the use of 
medicines, 101. 

Induced current, 78. 

Infusa, 100. 

Infusion of anthemidis, 649. 
of brayera, 846. 
of buchu, 528. 
of capsicum, 647. 
of cascarilla, 649. 
of chamomile, 649. 
of cinchona, 588. 
of cloves, 644. 
of digitalis, 363. 




GENERAL INDEX. 


889 


Infusion of gentian, com¬ 
pound, 638. 
of ginger, 645. 
of juniper, 731. 
of krameria, 442. 
of pareira brava, 729. 
of quassia, 637. 
of rhatany, 442. 
of senna, 693. 
of valerian, 117. 
of wild cherry, 642. 

Inunctions, mercurial, 523. 

Iodide of arsenic, 513. 
of mercury, 527. 
of potassium, 534. 
of silver, 471. 

Iodine, 528, 868. 
ointment, 534. 

Iodoform, 536. 
ointment, 541. 

Iodoformum, 536. 

Iodol, 541. 

Iodum, 528. 

Ipecacuanha, 654. 

as a diaphoretic, 748. 
as an expectorant, 763. 

Irish moss, 823. 

Iron, 472, 778, 863. 
by hydrogen, 475. 
Quevenne’s, 475. 

Iron rust, 475. 

Isopelletierine, 851. 


J. 

Jaborandi, 749. 

antagonism to atropine, 
755. 

Jaborandine, 749. 

Jaborine, 749. 

Jacket poultice, 833. 
Jaguarandy, 749. 

Jalap, 696. 

Jalapa, 696. 

Jamaica ginger, 645. 
Jamestown weed, 232. 
Jamguarandi, 749. 
Jamguarandy, 749. 

Janipha Manihot, 824. 
Jerusalem oak, 484. 

Jervine, 176, 392. 

Juglans, 689. 

Juice of conium, 325. 

Juices, 100. 

Julienne soup, 30. 

Juniper, 629. 

Juniperus, 629. 


K. 

Kairin, 635. 

Kamala, 852. 

Kameela, 852. 
Kateleetronus, 83. 
Kawa, 741. 

Kentish ointment, 814. 
Kinic acid, 442. 

Kino, 442. 

Kino-tannic acid, 438. 
Kinovic acid, 442. 

Kola nut, 365. 


Koossin, 846. 

Koosso, 846. 

Ivoumys, 32. 

Krameria, 442. 

L. 

Labarraque’s solution, 869. 

Lactate of iron, 478. 

Lactic acid, 486. 

Lacto-phosphate of lime, 550. 

Lactucarium, 125. 

Lactucin, 125. 

Lady Webster pills, 691. 

Lanolin, 827. 

Lard, 826. 

Laudanine, 178. 

Laudanum, 171. 
deodorized, 171. 

Lavandula, 648. 

Lavender, 648. 

Laxatives, 676. 

Lead, 445, 863. 
acetate of, 455. 
carbonate of, 456. 
ethyl, 453. 
nitrate of, 456. 
oxide of, 454. 
plaster, 454, 835. 
poisoning, 446. 
water, 455. 

Ledoyen’s disinfectant solu¬ 
tion, 456, 863. 

Lemon-juice, 432. 

Lemon-peel, 647. 

Lemons, essential salt of, 4 34. 

Levant wormseed, 846. 

Lichen starch, 823. 

Lichenin, 823. 

Lichstearic acid, 823. 

Light magnesia, 679. 

Lignum vitae, 559. 

Lily of the valley, 374. 

Lime, 841. 

as a disinfectant, 864. 
juice, 647. 

lacto-phosphate of, 550. 
liniment, 842. 
unslacked, 842. 
water, 842. 

Limonis cortex, 647. 

Lini farina, 833. 

Liniment of ammonia, 814. 
of camphor, 121. 
of cantharides, 810. 
of chloroform, 153. 
of lime, 842. 
of soap, 121. 
of turpentine, 814. 

Linimenta, 101. 

Linimentum calcis, 842. 
camphorae, 121. 
cantharidis, 810. 
chloroformi, 153. 
saponis, 121. 
terebinthinae, 814. 

Linum, 824. 

usitatissimum, 824. 

Liquid cosmoline, 831. 

Liquor acidi arseniosi, 513. 
ammonii acetatis, 756. 
arsenici et hydrargyri 
iodidi, 536. 


Liquor calcis, 842. 
ferri chloridi, 477. 
ferri subsulphatis, 476, 
762. 

ferri tersulphatis, 476. 
gutta-perchae, 836. 
hydrargyri nitratis, 819. 
iodi compositus, 534. 
magnesii citratis, 694. 
morphinae sulphatis, 172. 
pancreaticus, 854. 
plumbi subacetatis, 455. 
plumbi subacetatis di- 
lutus, 456. 
potassae, 838. 
potassii arsenitis, 513. 
potassii citratis, 721. 
sodae, 841. 
sodae chloratae, 869. 
sodii arseniatis, 513. 
zinci chloridi, 819. 

Liquores, 100. 

Liquorice, 824. 
root, 823. 

Lisbon diet-drink, 559. 

Litharge, 454. 

Lithii carbonas, 727. 

Lithium, bromide of, 296. 

Liver, action of cathartics on 
the, 671. 

Lobelia, 309, 763. 

Lobelic acid, 310. 

Lobeline, 309. 

Logwood, 442. 

Lozenges of cubebs, 741. 
of ipecacuanha, 659. 
of ipecacuanha and 
morphine, 659. 
of santonin, 850. 

Lugol’s solution, 534. 

Lunar caustic, 463. 

Lupulin, 124. 

Lupulina, 124. 

Lyctonine, 407. 

M. 

Mace, 642. 

Macis, 642. 

Magendie’s solution, 172. 

Magnesia., 838. 

ponderosa, 679. 

Magnesii carbonas, 679. 
citras granulatus, 694. 
sulphas, 693. 

Maizenic acid, 732. 

Male fern, 851. 

Malic acid, 443. 

Malt, 855. 

Manganese, 479. 

black oxide of, 479, 779. 
sulphate of, 479. 

Mangani oxidum nigrum, 
479. 

sulphas, 479. 

Manna, 678. 

Mannite, 678. 

Maranta, 825. 

arundinacea, 825. 

Massa copaibas, 739. 
hydrargyri, 523. 

Massage, 20. 

Mate, 363. 






890 


GENERAL INDEX. 


Materia Medica, 99. 

Matiein, 741. 

Matico, 741. 

Matricaria, 649. 

May-apple, 699. 

Meadow saffron, 551. 

Measures, 874. 

Meconie acid, 179. 

Meconine, 179. 

Medulla sassafras, 824. 

Mel rosae, 443. 

Melia Azedarach, 845. 

Melissa, 648. 

Mellita, 100. 

Mentha piperita, 648. 
viridis, 648. 

Menthol, 607. 

Mercurial ointment, 523. 
oleate, 523. 
pills, 523. 
plaster, 523. 
purgatives, 684. 

Mercury, 513. 

ammoniated, 528. 
hypodermic use of, 524. 
with chalk, 523. 

Metachloral, 191. 

Metallo-therapy, 37. 

Methenyl chloride, 143. 

Methylal, 196. 

Methylene bichloride, 153. 

Methysticin, 741. 

Mezereon, 561. 
ointment, 561. 

Mezereum, 561. 

Mild chloride of mercury, 
523. 

Milk of asafetida, 118. 

Milk foods, 30. 

punch, 31, 345. 
toast, panereatized, 33. 

Mineral emetics, 665. 
tonics, 472. 

Mistura ammoniaci, 769. 
cretae, 843. 
ferri composita, 476. 
glyeyrrhizie composita, 
824. 

potassii citratis, 717. 

Misturse, 100. 

Mixture of asafetida, 118. 
of chloroform, 163. 
of citrate of potassium, 
717. 

Molasses, 677. 

Monobromate of camphor, 

121 . 

Monsel’s solution, 476, 762. 

Morphinae acetas, 171. 
hydrochloras, 171. 
murias, 171. 
sulphas, 171. 

Morphine, 171. 

and chloral, 164. 

Moschus, 717. 

Motor points, 92. 

Mountain-climbing, 50. 

Mucilage of gum arabic, 822. 
of quince seeds, 824. 
of sassafras pith, 824. 
of slippery elm bark, 
822. 

of tragacanth, 822. 


Mucilagines, 100. 

Mucuna, 852. 

Mulled wine, 345. 

Muriate of ammonia, 763- 
765. 

of morphine, 171. 
Muriatic acid, 482. 

as a caustic, 820. 
Muscarine, antidote for, 362. 
Musk, 115. 

Mustard, 811. 

as an emetic, 665. 
paper, 813. 
plaster, 812. 

Mutton suet, 826. 

Myristica, 644. 

Myronic acid, 812. 

Myrrh, 778. 

Myrrha, 778. 

N. 

Napelline, 408. 

Naphthalol, 624. 

Narceine, 172. 

Narcotics, 762. 

Narcotine, 176. 

Nataloin, 689. 

Nauseating diaphoretics, 745— 
748. 

expectorants, 763. 
Nectandra, 638. 

Nervines, 112. 

Neutral mixture, 719, 749. 
Nicotianine, 315. 

Nicotine, 315. 

Nitrate of ammonium, 331. 
of lead, 456. 

of mercury, solution of, 
819. 

of potassium, 722. 
of silver, 463. 
of sodium, 722. 

Nitre, 722. 

Nitric acid, 482. 

as a caustic, 819. 

Nitrite of amyl, 298. 
of ethyl, 309. 
of potassium, 307. 
of sodium, 307. 

Nitrites, action of, on the 
blood, 303. 

Nitrogen monoxide, 131. 
Nitroglycerin, 308. 
Nitro-hydrochloric acid, 484. 
Nitro-muriatic acid, 484. 
Nitrous acid, 483. 
oxide, 131. 

Norwood’s tincture of vera- 
trum viride, 398. 

Nutgall, 441. 

Nutmeg, 644. 

Nutrients, 112. 

Nutritive enemata, 35. 

Nux vomica, 253. 

O. 

Oatmeal porridge, 32. 

Ohm’s law, 75. 

Oil of amber, 123. 
of anise, 648. 
of cajuput, 647. 


Oil of camphor, 121. 
of caraway, 648. 
of chenopodium, 651. 
of cinnamon, 644. 
of cloves, 644. 
of copaiba, 739. 
of coriander, 648. 
of cubeb, 741. 
of erigeron, 731. 
of eucalyptus, 589. 
of fennel, 648. 
of gaultheria, 622, 648. 
of juniper, 731. 
of lavender, 648. 
of marjoram, 648. 
of mentha pulegium, 7S3. 
of mustard, 812. 
of myristica, 644. 
of nutmeg, 644. 
of pennyroyal, 783. 
of pepper, 645. 
of peppermint, 607, 648. 
of phosphorus, 498. 
of pimento, 645. 
of rosemary, 648. 
of rue, 780. 
of sandal-wood, 731. 
of sassafras, 648. 
of savine, 780. 
of spearmint, 648. 
of tansy, 586. 
of tar, 776. 

of turpentine, 733, 813. 
of valerian, 116. 
of vitriol, 479. 
of wine, heavy, 123. 
of wormseed, 846. 

Ointment, 101. 

of ammoniated mercury, 
528. 

of antimony, 391. 
of belladonna, 231. 
of carbonate of lead, 456. 
of gallic acid, 441. 
of galls, 441. 
of iodide of potassium, 
536. 

of iodine, 534. 
of mercury, 523. 
of mezereon, 561. 
of nutgall, 441. 
of oxide of zinc, 460. 
of red iodide of mercury, 
527. 

of rose-water, 443. 
of stramonium, 232. 
of tannic acid, 440. 
of veratrine, 399. 
of white precipitate, 528. 
of yellow oxide of mer¬ 
cury, 527. 

Olea destillata, 100. 

Oleata, 100. 

Oleate of mercury, 523. 
of veratrine, 399. 

Oleoresin of black pepper, 
646. 

of capsicum, 647. 
of cubeb, 741. 
of fern, 851. 
of ginger, 645. 
of lupulin, 125. 

Oleoresinte, 100. 




GENERAL INDEX. 


891 


Oleum aethereum, 123. 
cajuputi, 645. 
chenopodii, 846. 
erigerontis, 731. 
morrhuae, 542. 
phosphoratum, 496. 
rieini, 6S2. 
sabinae, 780. 
santali, 731. 
succini, 123. 
terebinthinae, 733. 
theobromae, 826. 
tiglii, 704. 

Opianine, 179. ‘ 

Opium, 154. 

alkaloids, 171. 
denarcotized, 170. 
poisoning by, 166. 
Turkey, 154. 

Orange flower water, 646. 
flowers, 646. 
peel, 646. 

Oxalate of cerium, 459. 
of potassium, 434. 

Oxalic acid, 434. 

Oxide of antimony, 385. 
of ethyl, 137. 
of iron, hydrated, 475, 
863. 

of lead, 454. 
of silver, 471. 
of zinc, 460. 

Oxytocics, 784. 

Oysters, pancreatized, 35. 

Oyster-shell, 843. 

P. 

Pale catechu, 442. 
cinchona, 563. 
rose, 443. 

Pancreatic diastase, 854. 
extracts, 854. 

Pancreatin, 854. 

Pancreatized milk-toast, 35. 

Papain, 856. 

Papaverine, 177. 

Papayotin, 856. 

Parachinanisols, 634. 

Paraglin, 558. 

Paraglinic acid, 558. 

Paraguay tea, 364. 

Paraldehyde, 193. 

Paramorphine, 176. 

Paregoric, 171. 

Pareira, 728. 
brava, 728. 

Parsley, 780. 
sago, 825. 

Pearlash, 719. 

Pediluvium, 758. 

Pelletierine, 851. 

Pellitory, 801. 

Pelosine, 638. 

Pepo, 851. 

Pepper, 645. 

Peppermint, 648. 
water, 648. 

Pepsin, 853. 

Pepsina, 853. 

Pepsinum saccharatum, 853. 

Peptonized beef tea, 35. 
gruel, 34. 


Peptonized milk, 34. 
oysters, 35. 

Permanganate of potassium, 
781, 866. 

Petrolatum, 831. 
Petroselinum, 780. 
Pharmacology, 99. 
Pharmacopoeia, 99. 
Pharmacy, 99. 

Phenic acid, 594. 

Phenylic alcohol, 594. 
Phosphate of calcium, 548. 
of iron, 479. 
of sodium, 694. 
Phosphide of zinc, 496. 
Phosphoric acid, 548, 785. 
Phosphorus, 487. 
antidote to, 495. 
oil of, 496. 

Physostigma, 271. 
Physostigmine, 271. 
Picra-aconitine, 480. 

Picric acid, 592. 
Pikropodophyllin, 699. 

Pill of aloes, 691. 

of aloes and asafetida, 
691. 

of aloes and iron, 691. 
of aloes and mastic, 691. 
of aloes and myrrh, 691. 
of asafetida, 118. 
of carbonate of iron, 476. 
of iron, 476. 
of mercury, 523. 
of opium, 170. 
of rhubarb, 688. 
Pilocarpine, 749. 

antagonism with atro¬ 
pine, 755. 

Pilocarpus, 749. 

Pilula ferri carbonatis, 476. 
Pilulae, 101. 

asafoetidae, 118. 
catharticae composite, 
698. 

ferri composite, 476. 
opii, 170. 
phosphori, 496. 
rhei, 688. 

rhei eompositae, 688. 
Pimenta, 645. 

Pimento, 645. 

Pinkroot, 844. 

Piper, 645. 

methysticum, 741. 
Piperin, 645. 

Pipsissewa, 730. 

Pitch, 776. 

Pix Burgundica, 814. 

liquida, 775. 

Plasma, 830. 

Plaster of ammoniac, 769. 
of ammoniac with mer¬ 
cury, 769. 

of Burgundy pitch, 814. 
of Canada pitch, 814. 
of mercury, 523. 
of pitch with cantharides, 
814. 

Plumbi acetas, 455. 
carbonas, 456. 
nitras, 456. 
oxidum, 454. 


Plumbum, 445. 

Podophyllin, 699. 
Podophyllinic acid, 699. 
Podophyllotoxin, 699. 
Podophyllum, 699. 

Polygalic acid, 768. 
Pomegranate rind, 851. 
Poppy, 154. 

Porphyroxine, 78. 

Porridge, 32. 

Potassa, 816, 838. 
cum calce, 817. 
sulphurata, 681. 

Potassii acetas, 720. 
bicarbonas, 719. 
bitartras, 721. 
bromidum, 285. 
carbonas, 719. 
chloras, 724. 
citras, 719. 
cyanidum, 429. 
et sodii tartras, 695. 
iodidum, 534. 
nitras, 722. 
nitris, 722. 
permanganas, 866. 
sulphas, 695, 721. 
tartras, 721. 

Potassium, 713. 

Poultices, 831. 

Precipitated carbonate of cal¬ 
cium, 843. 

carbonate of iron, 476. 
carbonate of zinc, 460. 
phosphate of calcium, 
548. 

sulphur, 680. 

Prepared chalk, 843. 

oyster-shell, 843. 
Prescribing, art of, 107. 

Pride of China, 845. 

Primary current, 78. 
Propenyl alcohol, 827. 
Propylamin, 785. 

Protectives, 835. 

Protiodide of mercury, 527. 
Prunes, 677. 

Prunus Yirginiana, 642. 
Prussic acid, 419. 
Pseudaconitine, 408. 
Pseudomorphine, 179. 
Puecine, 659. 

Pulveres, 101. 

Pulvis aromaticus, 644. 

effervescens compositus, 
695. 

glycyrrhizse compositus, 
693. 

ipecacuanha) et opii, 748. 
jalaprn compositus, 695. 
opii, 170. 
parturiens, 792. 
rhei compositus, 688. 
Pumpkin seed, 851. 

Punch, milk, 31. 

Purgative enemas, 673. 
Purgatives, 666. 

Purges, 682. 

Purging cassia, 677. 

Purified aloes, 689. 

animal charcoal, 857. 
chloroform, 143. 
Pyrethrum, 801. 






892 

Pyridin, 700. 

Pyrogallic acid, 439. 
Pyrophosphate of iron, 479. 
Pyroxylin, 835. 

Pyroxylinum, 835. 

Q. 

Quassia, 637. 

Quassin, 637. 

Quercitron, 443. 

Quercus alba, 443. 

tinctoria, 443. 

Quevenne’s iron, 475. 

Quince seed, 824. 

Quinidinas sulphas, 586. 
Quinidine, 586. 

Quininm bisulphas, 585. 

sulphas, 464. 

Quinine, 564. 

dihydroxyle, 577. 
hydrobromate of, 585. 
tannate of, 586. 
Quinoidin, 588. 

Quinoidine (animal), 577. 

R. 

Reactions of degeneration, 8S. 
Rectal alimentation, 35. 

Red cinchona, 563. 

iodide of mercury, 527. 
ipecacuanha, 652. 
oxide of mercury, 527. 
precipitate, 527. 
rose, 443. 

sulphuret of mercury, 
528. 

wine, 332. 

Reduced iron, 475. 
Refrigerant diaphoretics, 745- 
749. 

diuretics, 713. 

Remedies, extraneous, 112. 

systemic, 112. 

Rennet, 853. 

Resin of jalap, 697. 
of May-apple, 700. 
of podophyllum, 700. 
of scammony, 698. 
of veratrum viride, 395. 
plaster, 454. 

Resina, 733. 

Resinas, 101. 

Resorcin, 609. 

Rest-cure, 40. 

Rhabarbin, 688. 
lthamnus, 678. 

Rhatany, 442. 

Rhein, 688. 

Rheum, 686. 
llhodeoretin, 696. 

Rhubarb, 671, 686., 

Rhus glabra, 443. 

Rochelle salt, 695. 

Roman chamomile, 649. 

Rosa centifolia, 443. 

Gallica, 443. 

Rosemary, 648. 

Rose-water, 443. 

Rosin, 733. 

Rosmarinus, 648. 

Rottlera, 852. 


GENERAL INDEX. 

Rottlerin, 852. 

Royal yellow bark, 563. 
Rubefacients, 805, 811. 

Rue, 779. 

Russian bath, 743. 

Ruta, 779. 

Rutin, 779. 

S. 

Sabadilla, 399. 

Sabadilline, 399. 

Sabina, 779. 

Saccharate of lime, 605. 
Saccharated carbonate of iron, 
476. 

iodide of iron, 478. 
Saccharin, 830. 

Saccharum, 677. 

lactis, 677. 

Sage, 648. 

Sago, 825. 

porridge, 33. 

Sagus Rumphii, 825. 

Sal ammoniac, 765. 

prunelle, 722. 

Salicin, 622. 

Salicylic acid, 611. 

as an antipyretic, 619. 
wadding, 621. 

Salicyluric acid, 616. 

Saline cathartics, 693. 

Salol, 624. 

Salseparin, 558. 

Salt of lemons, 434. 

of sorrel, 434. 

Saltpetre, 722. 

Salvia, 648. 

Sanguinaria, 659. 
Sanguinarine, 659. 

Santonica, 846. 

Santonin, 847. 

Santoninate of sodium, 850. 
Santoninic acid, 847. 
Santoninum, 847. 

Saponin, 768. 

Sarsaparilla, 558. 
Sarsaparillin, 558. 

Sassafras, 561. 

pith, 824. 

Savine, 779. 

Scammonium, 698. 
Scammony, 698. 

Scheele’s green, 511. 

Soil la, 708, 775. 

Scillain, 708. 

Scillin, 708. 

Scillipicrin, 708. 

Scillitin, 708. 

Seillitoxin, 708. 

Sclerotinic acid, 785. 
Sclerotium, 784. 

Scoparine, 712. 

Scoparius, 712. 

Scudamore’s mixture, 556. 
Sculein, 708. 

Sedative expectorants, 759. 
Seidlitz powder, 695. 

Senega, 766. 

Senna, 691. 

Serpentaria, 648. 
Sesquichloride of iron, 477. 

' Sesquioxide of iron, 512. 


Sex in relation to dose, 106. 
Shore oil, 542. 

Sialagogues, 801. 

Sick, feeding of the, 26. 
Silver, 463. 

Simaruba, 637. 

Simple bitters, 637. 

diaphoretics, 746-749. 
Sinapin, 812. 

Sinapinic acid, 812. 

Sinapis alba, 811. 

nigra, 811. 

Sinapisin, 812. 

Sipeerine, 638. 

Slippery elm, 833. 

elm bark, 822. 
Smelling-salts, 802. 

Smilacin, 558. 

Smut of Indian corn, 799. 
Soap liniment, 121. 

plaster, 835. 

Socaloin, 689. 

Socotrine aloes, 689. 

Soda, 840. 

powders, 840. 

Sodii acetas, 841. 
arsenias, 513. 
biboras, 870. 
bicarbonas, 841. 
bicarbonas venalis, 841. 
boras, 870. 
bromidum, 296. 
carbonas, 841. 
carbonas exsiccatus, 841. 
nitras, 841. 
phosphas, 694. 
santoninas, 850. 
sulphas, 694. 

Sodium, 838. 

Solution of acetate of ammo¬ 
nium, 756. 

of arseniate of sodium, 
513. 

of arsenious acid, 513. 
of arsenite of potassium, 
513. 

of chloride of zinc, 819. 
of chlorinated soda, 869. 
of citrate of magnesium. 
694. 

of citrate of potassium, 
719 . 

of gutta-percha, 836. 
of iodide of arsenic and 
mercury, 536. 
of lime, 842. 
of nitrate of mercury, 
819. 

of persulphate of iron, 
476. 

of potassa, 819, 838. 
of soda, 841. 
of subacetate of lead, 
457. 

of subsulphate of iron, 
476. 

of sulphate of morphine, 
172. 

of tersulphate of iron, 
476. 

Solvents, 762. 

Somnifacients, 112. 

Soups, 29. 




GENERAL INDEX. 


Spanish flies, 807. 

Sparteine, 381, 712. 
Spasmodic ergotism, 798. 
Spearmint, 648. 

water, 648. 

Spermaceti, 826. 

Spice plasters, 813. 

Spigolia, 844. 

Marilandica, 844. 

Spinal cord, galvanization of 
the, 95. 

Spirit of ammonia, 331. 
of anise, 648. 
of camphor, 121. 
of chloroform, 153. 
of cinnamon, 644. 
of juniper, 731. 
of lavender, 647. 
of lemon, 647. 
of Mindererus, 756. 
of nitrous ether, 713, 
756. 

of peppermint, 648. 
of spearmint, 648. 
Spiritus, 100. 

aetheris eompositus, 123. 
mtheris nitrosi, 713, 756. 
ammonias, 331. 
ammonias aromaticus, 
331. 

chloroformi, 153. 
frumenti, 331. 
vini Galliei, 331. 

Squill, 708. 

as an emetic, 654. 
as an expectorant, 775. 
St. Ignatius’ bean, 270. 

Star anise, 648. 
Sticking-plaster, 454, 733. 
Stigmata of Zea mays, 732. 
Stimulating expectorants, 
759, 765. 

Stomach-pump siphon, 167. 
Straits oil, 542. 

Stramonii folia, 232. 
semen, 232. 

Stramonium leaves, 232. 
seed, 232. 

Stronger alcohol, 331. 
ether, 137. 
spices, 813. 

water of ammonia, 331, 
807. 

Strophanthidine, 376. 
Strophanthine, 376. 
Strophanthus, 376. 
Strychninas sulphas, 269. 
Strychnine, 253. 

poisoning by, 264. 
Stupes, 813. 

Subacetate of copper, 461. 
of lead, 455. 

Subcarbonate of bismuth, 456. 
Sublimed sulphur, 680. 
Subnitrate of bismuth, 456. 
Succi, 100. 

Succinum, 123. 

Succus conii, 325. 

limonis, 432. 

Sugar, 677. 

of lead, 455. 
of milk, 677. 

Sulphate of aluminium, 445. 


Sulphate of ammonium, 331, 
765. 

of atropine, 232. 
of bebeerine, 638. 
of cadmium, 462. 
of cinchonidine, 586. 
of cinchonine, 586. 
of copper, 461, 665, 820. 
of hyoscyamine, 234. 
of iron, 476. 
of iron, impure, 864. 
of iron and ammonium, 
479. 

of magnesium, 693. 
of manganese, 479. 
of morphine, 171. 
of nectandra, 641. 
of potash, 695, 721. 
of quinidine, 585. 
of quinine, 564. 
of sodium, 694. 
of strychnine, 269. 
of zinc, 459, 665, 820. 

Sulphide of calcium, 682. 

Sulphites, 480. 

Sulpho-sinapisin, 812. 

Sulphovinate of sodium, 695. 

Sulphur, 680. 
lotum, 680. 
ointment, 681. 
prmcipitatum, 680. 
sublimatum, 680. 

Sulphurated antimony, 385. 
lime, 682. 
potassa, 681. 

Sulphuret of antimony, 385. 
of potassium, 681. 

Sulphuretted hydrogen, 769. 

Sulphuric acid, 479. 
as a caustic, 819. 

Sulphurous acid, 872. 

Sumach, 443. 

Suppositoria, 101. 

Suppositories of asafetida, 
118. 

of morphine, 172. 
of sweet cassava, 824. 
of tannic acid, 441. 

Sweet orange peel, 646. 

Sweet spirit of nitre, 713, 
756. 

Sweet tincture of rhubarb, 

688 . 

Sydenham’s laudanum, 171. 

Sympathetic, galvanization 
of the, 94. 

Syrup, 100. 

of althaea, 824. 
of ginger, 645. 
of iodide of iron, 479. 
of ipecacuanha, 659. 
of krameria, 442. 
of lime, 842. 
of red rose, 443. 
of rhatany, 442. 
of rhubarb, 688. 
of sarsaparilla, com¬ 
pound, 559. 
of senega, 768. 
of senna, 693. 
of squill, 710, 775. 
of sweet orange peel, 647. 
of tar, 776. 


893 

Syrup of the phosphates, com¬ 
pound, 550. 
of Tolu, 775. 
of wild cherry, 643. 
Syrupi, 100. 

Syrupus calcis, 842. 
fuscus, 677. 

Systemic remedies, 112. 


T. 

Tabacum, 315. 

Table of proportion by meas¬ 
ure of alcohol contained 
in one hundred parts of 
different wines, etc., 877. 
Table of relation of weights 
and measures of the U.S. 
Pharmacopoeia to each 
other, 875. 

Tables of relation of weights 
of the U.S. Pharmacopoeia 
to metrical weights, 876. 
Table of weights and meas¬ 
ures of the metrical sys¬ 
tem, 874. 

Table of weights and meas¬ 
ures of the U.S. Pharmaco¬ 
poeia, 875. 

Table showing results of cold- 
water treatment of typhus 
and typhoid fever, 64. 
Tamiin, 846. 

Tamarind, 677. 

Tamarindus, 677. 

Tanacetum, 782. 

Tannate of cannabene, 202. 

of quinine, 586. 

Tannic acid, 438. 

Tansy, 782. 

Tapioca, 824. 

porridge, 33. 

Tar, 775. 

ointment, 776. 
water, 776. 

Taraxacum, 561. 

Tartar, 430. 

Tartar emetic, 385, 665, 573, 
748. 

antidote to, 391. 

Tartaric acid, 430. 

Tartrate of antimony and 
potassium, 385. 
of iron and ammonium, 
478. 

of iron and potassium, 
478. 

of potassium, 721. 
of potassium and sodium, 
695. 

Tea, beef, 29. 

Temperament, 105. 
Terchloride of formyl, 143. 
Terebene, 776. 

Terebinthina, 732. 

Canadensis, 732. 
Tersulphuret of antimony, 
385. 

Thallin, 634. 

Thebaine, 176. 

Theine, 364. 

Theobroma, 239. 




894 


GENERAL INDEX. 


Therapeutics, 99. 

Thymol, 608, 852. 

Time for administration of 
drugs, 107. 

Tinctura ferri chloridi, 477. 
opii, 171. 
opii acetata, 171. 
opii camphorata, 171. 
opii deodorata, 171. 

Tincturse, 100. 

Tincture of aconite, 418. 
of aloes, 691. 
of aloes and myrrh, 691. 
of arnica, 406. 
of asafetida, 118. 
of belladonna, 230. 
of benzoin, 774. 
of benzoin, compound, 
774. 

of bitter orange peel, 647. 
of black hellebore, 705. 
of bloodroot, 659. 
of Calabar bean, 282. 
of cannabis indica, 202. 
of cantharides, 810. 
of capsicum, 647. 
of cardamom, 645. 
of castor, 116. 
of catechu, 442. 
of chirata, 641. 
of chloride of iron, 477. 
of cimicifuga, 126. 
of cinchona, 588. 
of cinnamon, 644. 
of colchicum, 557. 
of columbo, 641. 
of eonium, 325. 
of cubeb, 741. 
of digitalis, 363. 
of galls, 441. 
of gelsemium, 315. 
of gentian, 638. 
of ginger, 645. 
of guaiac, 560. 
of guaiac, ammoniated, 
560. 

of hellebore, 705. 
of hemp, 202. 
of hops, 124. 
of hyoscyamus, 235. 
of ignatia, 270. 
of iodine, 534. 
of kino, 442. 
of krameria, 443. 
of lobelia, 311, 763. 
of lupulin, 124. 
of matieo, 739. 
of musk, 116. 
of nutgall, 441. 
of nux vomica, 253. 
of opium, 171. 
of opium, acetated, 171. 
of opium, camphorated, 
171. 

of opium, deodorized, 
171. 

of quassia, 637. 
of rhatany, 443. 
of rhubarb, 688. 
of rhubarb and senna, 
688. 

of sanguinaria, 660. 
of serpentaria, 649. 


Tincture of squill, 710. 
of stramonium, 233. 
of sweet orange peel, 647. 
of Tolu, 775. 
of valerian, 117. 
of valerian, ammoniated, 
117. 

of veratrum viride, 398. 
Tobacco, 315. 

Tomato porridge, 33. 

Tonics, 112. 

Tragacanth, 822. 
Tragacantha, 822. 
Trimethylamin, 785. 
Trinitro-cellulose, 835. 

Tripoli senna, 692. 
Trituration of elaterium, 702. 
Troches, 101. 

Trochisci acidi tannici, 440. 
ammonii chloridi, 768. 
catechu, 442. 
ipecacuanhse, 659, 763. 
morph inse et ipecacu¬ 
anha, 659, 764. 
Trypsin, 855. 

Turkish bath, 743. 
Turpentine, 732, 746. 

as an anthelmintic, 851. 
stupes, 735. 

Turpeth mineral, 528. 


U. 

Ulmus, 822. 

fulva, 822. 

Unbolted flour, 677. 
Unguenta, 101. 

acidi gallici, 441. 
acidi tannici, 441. 
Unguentum antimonii, 391. 
aquae rosas, 826. 
belladonnae, 231. 
gallae, 44. 
hydrargyri, 523. 
hydrargyri ammoniati, 
528. 

iodi, 534. 
iodoform i, 541. 
mezerei, 561. 
picis liquidae, 776. 
plumbi carbonati, 456. 
potassii iodidi, 536. 
sulphuris, 681. 
veratrinae, 399. 
zinci oxidi, 460. 

Urea, elimination of, by the 
skin, 747. 

Urethan, 195. 

Urobutylchloralic acid, 193. 
Urochloralic acid, 184. 

Ursin, 729. 

Urson, 729. 

Ustilago maidis, 799. 

Uva ursi, 729. 

V. 

Valerian, 116. 

Valeriana, 116. 

Valerianate of ammonium, 
117. 

of amyl, 309. 


Valerianic acid, 117. 

Vapor bath, 743. 

Vaseline, 831. 

Vegetable acids, 430. 

Veratralbine, 399. 

Veratrine, 399. 
ointment, 405. 

Veratroidine, 392. 

Veratrum album, 398. 
viride, 392. 

viride as a diaphoretic, 
749. 

viride, resin of, 395. 
viride, tincture of, 398. 

Verdigris, 461. 

Vermicelli soup, 30. 

Vermicides, 844. 

Vermifuges, 844. 

Vesicatories, 806. 

Vienna paste, 817. 

Vina, 100. 

Vinegar, 433. 

of bloodroot, 659. 
of lobelia, 311. 
of opium, 170. 
of sanguinaria, 659. 
of squill, 710. 

Vinum album, 332. 
aloes, 691. 
ipecacuanhse, 659. 
rubi-um, 332. 

Virginia snakeroot, 649. 

Viridine, 392. 

Vitriolated tartar, 695. 

Volt, 76. 

Vomiting, 650. 

Vomiting, treatment of ex¬ 
cessive, 653. 

W. 

Wahoo, 679. 

Warburg’s tincture, 588. 

Warming plaster, 814. 

Wash, black, 528. 
yellow, 528. 

Washed sulphur, 680. 

Water as a diuretic, 706. 

in the treatment of cor¬ 
pulence, 48. 
of ammonia, 807. 

Wax, 826. 

AV’eights and measures of the 
metrical system, 874. 

Weights and measures of the 
United States Pharmaoo- 
poeia, 874. 

West India pepper, 646. 

Wheat, cracked, 677. 

Whey, wine of, 31. 

Whisky, 331. 

White arsenic, 498. 
galls, 441. 
ginger, 645. 
hellebore, 398. 
lead, 456. 
mustard, 812. 
oak, 443. 
pepper, 645. 
precipitate, 528. 
precipitate ointment, 528. 
turpentine, 732. 
vitriol, 459. 




GENERAL INDEX. 


895 


White wax, 826. 
wine, 332. 

Wild cherry, 642. 

Wine of aloes, 691. 
of antimony, 391. 
of colchicum root, 559. 
of colchicum seed, 559. 
of ergot, 798. 
of ipecacuanha, 659. 
of lobelia, 311. 
of opium, 171. 
of rhubarb, 6S8. 
whey, 31. 

Wines, 332. 


Wonnseed, 845. 
oil, 846. 

X. 

Xanthopuocine, 639. 

Y. 

Yaupon, 365. 

Yellow cinchona, 563. 
jessamine, 311. 
oxide of mercury, 527. 
sulphate of mercury, 528. 
wash, 528. 
wax, 826. 

Young’s rule for doses, 106. 


Z. 

Zea mays, stigmata of, 732. 
Zinc, 459. 

phosphide of, 496. 

Zinci acetas, 460, 

carbonas praecipitata, 
460. 

chloridum, 818. 
oxidum, 459. 
oxidum venale, 460. 
sulphas, 459. 

Zincum, 459. 

Zingiber, 645. 






INDEX OF DISEASES 


A. 

Abrasions: 

solution of gutta-percha, 
836. 

Abscess: 

tannic acid, 440. 
alcohol, 342. 
carbolic acid, 601. 
permanganate of potas¬ 
sium, 867. 
Achromatopsia : 

metallo-therapy for, 37. 
Acidity of stomach: 

ammonia, 329. 

Acne: 

arsenic, 509. 
iehthyol, 562. 
iodine, 533. 
phosphorus, 4S8. 
rosemary, 648. 
solution of nitrate of 
mercury, 819. 

Acne rosacea : 
cajuput, 647. 
solution of nitrate of 
mercury, 819. 
Aconite-poisoning : 
alcohol, 343. 
treatment, 418. 

Adenitis , suppurative: 
iodol, 542. 

Adhesions, breaking up of: 

massage, 25. 

Adynamic fevers : 
ammonia, 325. 
alcohol, 342. 
camphor, 121. 
digitalis, 360. 
feeding in, 26. 
mineral acids, 478. 
opium, 172. 

chlorate of potassium, 
726. 

acetate of ammonium, 
756. 

spirit of nitrous ether, 
713, 757. 
turpentine, 732. 
valerian, 116. 

Ague : 

chloroform for, 150. 
Alcoholic intoxication: 

ammonia, 328. 
Alimentary inflammation : 
demulcents, 821. 


Alopecia : 

jaborandi, 755. 

Amaurosis: 

strychnine, 263. 
santonin, 847. 

Amenorrhcea : 
iron, 778. 
cantharides, 742. 
aloes, 690, 778. 
turpentine, 736. 
emmenagogues, 778. 
myrrh, 778. 
hellebore, 779. 
iron, 782. 
savine, 779. 
senega, 768. 
rue, 780. 
apiol, 781. 

gossypii radicis cortex, 
799. 

guaiac, 782. 
cotton root, 799. 
permanganate of potas¬ 
sium, 782. 

Ammoniacal urine : 
boracic acid, 872. 

Ansemia : 

iron, 475. 
quinine, 581. 

Anesthesia of skin : 
electricity, 93. 
metallo-therapy, 37. 

Aneurism : 

digitalis, 359. 

iodide of potassium, 535. 

ergot, 794. 

Angina : 

gum arabic, 822. 
carbolic acid, 602. 
chlorate of potassium, 
727. 

Angina pectoris: 

nitrite of amyl, 305. 
nitrite of potassium, 
307. 

nitrite of sodium, 307. 
nitroglycerin, 309. 

Anginose scarlet fever , 57. 

Animal poisoning: 
ammonia, 329. 
alcohol, 343. 

Anorexia : 

quassia, 637. 
gentian, 638. 
columbo, 641. 
chamomile, 649. 

57 


Aortic disease : 
digitalis, 358. 

Aphthous sore mouth: 

chlorate of potassium, 

726. 

borax, 871. 
carbolic acid, 001. 

Apoplexy : 
ergot, 795. 

Arsenical poisoning : 
treatment, 512. 

Arterial excitement: 
aconite, 416. 
antimony, 390. 
gelsemium, 312. 
veratrum viride, 397. 

Ascarides ; 

anthelmintics, 844. 
oil of cajuput, 647. 

Ascites : 

elaterium, 702. 
cathartics, 676. 
chlorate of potassium, 

727. 

jalap, 697. 

Asthenopia : 

strychnine, 264. 

Asthma : 

belladonna, 221, 
emetics, 650. 
eucalyptus, 589. 
gelsemium, 314. 
hyoscine, 238. 
grindelia, 765. 
stramonium, 233. 
anaesthetics, 112. 
ether, 142. 
chloral, 187. 
nitrite of amyl, 305. 
lobelia, 311. 
nitroglycerin, 309. 
tobacco, 319. 
arsenic, 510. 
iodide of potassium, 535. 
valerianate of amyl, 309. 
pyridin, 760. 
sulphuretted hydrogen, 

770. 

Ataxic pneumonia, 115. 

Atheroma : 

digitalis, 359. 

B. 

Bed-sores : 

chloral, 186. 
protectives, 835. 

897 





898 


INDEX OF DISEASES. 


Belladonna-poisoning : 

treatment, 224. 

Biliary calculi: 

belladonna, 222. 
emetics, 650. 

Bilious fever : 
quinine, 583. 
calomel, 685. 
jaborandi, 754. 
Warburg’s tincture, 588. 
Biliousness: 

muriate of ammonia, 
767. 

nitro-hydrochloric acid, 
485. 

calomel, 686. 
podophyllum, 700. 
potassium salts, 720. 
taraxacum, 561. 

Bites : 

caustic potash, 816. 
Bladder, irritable: 
buehu, 728. 
hops, 124. 
pareira, 728. 

Indian corn silk, 732. 
Blennorrhagia : 

iodol, 542. 

Boils : 

cocaine, 250. 
phosphorus, 488. 
sulphide of calcium, 682. 
menthol, 607. 
sulphurated lime, 682. 
Bowel complaint: 

rhubarb, 688. 
Brain-softening: 

phosphorus, 488. 

Bright’s disease : 
caffeine, 373. 
cream of tartar, 721. 
jaborandi, 754. 
gallic acid, 441. 
iodide of potassium, 534. 
tincture of the chloride 
of iron, 477. 
diuretics, 706. 
diaphoretics, 556. 
water, 706, 834. 
Bronchial secretion : 

astringents, 762. 
Bronchitis : 

alteratives, 763. 
antimony, 390. 
apomorphia, 664. 
asafetida, 118. 

Calabar bean, 281. 
cocaine, 250. 
benzoic acid, 773. 
oil of amber, 123. 
lobelia, 310. 
oil of eucalyptus, 591. 
oil of turpentine, 735, 
764. 

tartar emetic, 396. 
cimicifuga, 126. 
opium, 165. 

Banguinaria, 659. 
copaiba, 739. 
cubebs, 741. 
grindelia, 765. 
inhalations, 763. 
ipecacuanha, 658. 


Bronchitis : 

chloral, 186. 

chloride of ammonium, 
767. 

senega, 768. 
alkalies, 759. 
pyridin, 760. 
ammoniac, 769. 
garlic, 775. 
squill, 775. 

oil of sandal-wood, 735. 
strychnine, 264. 
sulphuretted hydrogen, 
770. 

tar, 776. 
terebene, 776. 

Burgundy pitch, 814. 
demulcents, 820. 
liquorice, 824. 
Bronchorrhcea : 

gallic acid, 441, 760. 
alum, 414. 
astringents, 762. 

Bruises : 

camphor, 121. 
ichthyol, 562. 

Buboes : 

iodoform, 537. 
chloral, 186. 

Burns : 

Carron oil, 842. 
carbonate of lead, 456. 
carbolic acid, 601. 
ichthyol, 562. 

Kentish ointment, 814. 
chalk, 843. 

Bursx, inflamed: 

carbolic acid injections, 
602. 


C. 

Cachexia : 

glycerin, 830. 

Calculi : 

anaesthetics, 112. 
benzoic acid, 773. 
calculi, 222. 
water, 834. 

Cancer : 

arsenic, 817. 
resorcin, 611. 

Chian turpentine, 737. 
chloral, 188. 
conium, 325. 
solution of nitrate of mer¬ 
cury, 819. 
iodoform, 539. 

Cancer of stomach : 

malt, 855. 

Cancrum oris : 

nitric acid, 483. 
Carbuncle : 

cocaine, 250. 
menthol, 607. 

Carcinoma of stomach : 

bismuth, 458. 

Cardiac disease, chronic : 
aconite, 416. 
digitalis, 357. 

Hoffmann’s anodyne, 
123. 

nitrite of amyl, 305. 


Cardiac disease, chronic: 

veratrum viride, 397. 
Cardiac dropsy : 
caffeine, 364. 
squill, 710. 
digitalis, 359, 711. 
adonidine, 383. 

Cardiac failure : 
ammonia, 329. 
nitrite of amyl, 306. 
Cardialgia : 

antacids, 837. 
charcoal, 858. 

Ca r ies : 

cod-liver oil, 546. 
cloves, 644. 

Cataract: 

phosphorus, 488. 
atropine, 227. 

Catarrh : 

balsam of Peru, 774. 
balsam of Tolu, 774. 
chloride of ammonium, 
763. 

flaxseed, 824. 
sulphuretted hydrogen, 
770. 

Catarrh, chronic : 

asafetida, 118. 

Catarrh of bladder : 
benzoic acid, 773. 
juniper, 629. 
grindelia, 765. 
thymol, 609. 
bethol, 625. 
salol, 624. 
naphthalol, 625. 

Catarrh, suffocative : 
allium, 775. 
apomorphine, 661. 
expectorants, 759. 
garlic, 775. 
emetics, 759. 

Catarrhal jaundice : 
citric acid, 433. 
benzoic acid, 773. 
expectorants, 759. 
Catarrhal pneumonia : 
cod-liver oil, 546. 
alteratives, 113, 763. 
iodine, 759. 

sulphuretted hydrogen, 
168. 

Cerebral excitement: 

bromide of potassium, 
292. 

Cerebral softening : 

phosphorus in, 488. 
Cerebritis : 

electricity, 94. 

Chancres : 

iodoform, 539. 
escharotics, 815. 
Canquoin’s paste, 818. 
solution of nitrate of 
mercury, 819. 
corrosive sublimate, 
819. 

black and yellow washes, 
528. 

resorcin, 611. 
chloride of zinc, 818. 
iodol, 542. 




INDEX OF DISEASES. 


899 


Chancres: 

nitric acid, 483, 819. 
Chapped hands, lips, nipples : 
benzoic acid, 774. 
solution of gutta-percha, 
836. 

Chloral-poisoning: 

treatment of, 186. 
Cholera : 

ammonia, 330. 
camphor, 121. 
chloral, 187. 
sulphuric acid, 480. 
nitrite of amyl, 306. 
salol, 624. 

Cholera infantum : 

sulphuric acid, 480. 
chlorate of potassium, 
727. 

resorcin, 610. 
cold, 69. 

Cholerine: 

ipecac, 657. 

Chordee: 

brominated camphor, 

121 . 

hops, 125. 
camphor, 121. 

Chorea : 

arsenic, 509. 

Calabar bean, 281. 
cimicifuga, 126. 
chloral, 187. 
conium, 325. 
bromide of iron, 478. 
bromide of sodium, 479. 
lobelia, 311. 
oxide of zinc, 460. 
Cirrhosis : 

nitro-hydrochloric acid, 
485. 

Cold, a general: 

Dover’s powder, 749. 
hot baths, 743. 
diaphoretics, 745. 
alcohol, 758. 
boneset, 641. 
eupatorium, 641. 
garlic, 775. 
glycyrrhiza, 824. 

Colic : 

asafetida, 117. 
atropine, 287. 
belladonna, 221. 
cajuput, 647. 
chloroform, 150. 
ether, 142. 
antacids, 837. 
ginger, 645. 
opium, 165. 

valerianate of amyl, 
309. 

Colica pictonum : 
alum, 445. 
sulphuric acid, 480. 
belladonna, 221. 
chloroform, 150. 

Epsom salt, 693. 

Colitis : 

nitrate of silver, 469. 
sulphate of magnesium, 
693. 

injections, 674. 


Collapse : 

ammonia, 330. 
belladonna, 223. 
digitalis, 359. 
epispastics, 805. 
heat, 55. 
mustard, 805. 

Warburg’s tincture, 589. 
Colliquative sweats: 
gallic acid, 441. 
alum, 444. 
sulphuric acid, 480. 
belladonna, 223. 
ergot, 794. 
ipecacuanha, 657. 
Condylomata : 

nitric acid, 819. 
chromic acid, 820. 
carbolic acid, 601. 
Congestion of brain : 
elaterium, 702. 
ergot, 795. 

Congestion of cord : 

ergot, 795. 

Congestion, hepatic : 

nitro-hydrochloric acid, 
485. 

calomel, 686. 

Congestion, renal: 

juniper, 731. 
Conjunctivitis : 
alum, 444. 

sulphate of copper, 461. 
nitrate of silver, 467. 
yellow oxide of mercury, 
527. 

Constipation : 
alum, 445. 

compound cathartic pills, 
698. 

aloes, 690. 

citrate of magnesium, 
694. 

belladonna, 221. 

Epsom salt, 693. 
strychnine, 264. 
manna, 678. 
general treatment, 677. 
Calabar bean, 282. 
cascara sagrada, 679. 
castor oil, 683. 
podophyllum, 700. 
magnesia, 679. 
cracked wheat, 677. 
bran, 677. 
unbolted flour, 677. 
Indian meal, 677. 
forced enemata, 674. 
rhubarb, 688. 
sulphur, 680. 
gamboge, 703. 
seidlitz powder, 695. 
croton oil, 704. 
wahoo, 679. 

Consumption : 

cod-liver oil, 545. 

Contusions : 

ichthyol, 562. 

Convulsions : 

anaesthetics, 112. 
bromide of potassium, 
292. 

brominated camphor, 122. 


Convulsions: 
chloral, 186. 
emetics, 650. 
garlic, 775. 
lobelia, 311. 
nitrite of amyl, 301. 
corpulence, 44. 

Coryza : 

bismuth, 458. 
cocaine, 250. 
cubebs, 741, 782. 
errhines, 802. 
glycerin, 829. 
nitrite of amyl, 306. 

Cough, to quiet : 

belladonna, 222. 
prussic acid, 427. 

Cramps of pregnancy : 
chloral, 187. 

Croup, membranous : 
alum, 445. 
glycerin, 829. 
ipecacuanha, 635. 
jaborandi, 755. 
lime-water, 842. 
mercury, 519. 

Cuts: 

solution of gutta-percha, 
836. 

Cystitis, chronic : 
arbutin, 729. 
bethol, 625. 
boracic acid, 872. 
buchu, 728. 
iodine, 533. 
pareira brava, 728. 
naphthalol, 625. 
uva ursi, 729. 
turpentine, 735. 
copaiba, 738. 
cantharides, 742. 
salicylic acid, 620. 
resorcin, 610. 
zea mays, 732. 

Cystorrhcea : 
ergot, 796. 

D. 

Debility : 

prunus Yirginiana, 642. 
cod-liver oil, 547. 

Delirium of low fevers : 
musk, 115. 
valerian, 116. 
opium, 166. 
chloral, 185. 
blisters, 806. 

Delirium tremens : 
digitalis, 360. 
brominated camphor, 
122 . 

veratrum viride, 396. 
hops, 124. 
hyoscine, 238. 
opium, 164. 

bromide of potassium, 
292. 

chloral, 185. 
croton oil, 704. 
gamboge, 703. 

Depression : 

treatment of, 40. 





900 

Dermal growths: 

chromic acid, 820. 
nitric acid, 819. 

Diabetes: 

saccharin, 831. 
opium, 165. 
glycerin, 830. 
carbonate of lithium, 
727. 

thymol, 609. 
salol, 624. 
ergot, 795. 

Diabetes insipidus : 
opium, 165. 
ergot, 795. 

Diarrhoea : 

aromatics, 643. 
tannic acid, 440. 
catechu, 442. 
coca, 251. 
cold, 69. 
antacids, 837. 
haematoxylon, 442. 
alum, 444. 
acetate of lead, 455. 
bismuth, 458. 
eucalyptus, 589. 
oil of cajuput, 647. 
thymol, 609. 
syrup of lime, 842. 
geranium, 443. 
ipecacuanha, 654. 
sulphuric acid, 480. 
magnesia, 680. 
nitrous acid, 483. 
camphor, 121. 
opium, 165. 
pepsin, 854. 
resorcin, 610. 
belladonna, 223. 
strychnine, 264. 
castor oil, 683. 
rhubarb, 688. 
rhatany, 442. 
ergot, 794. 
lime-water, 842. 
charcoal, 858. 
kino, 442. 

Diarrhoea, chronic : 
bismuth, 458. 
sulphate of copper, 461. 
sulphate of iron, 475. 
sulphate of zinc, 459. 
nitro-muriatic acid, 485. 
magnesia, 680. 
oxide of zinc, 460. 
copaiba, 739. 
ergot, 795. 

phosphate of sodium, 
694. 

Digitalis-poisoning : 
treatment, 361. 

Dilatation of heart: 
digitalis, 356. 
convallaria, 374. 

Diphtheria: 

benzoic acid, 773. 
carbolic acid, 601. 
cold, 57. 
borax, 871. 
resorcin, 611. 
jaborandi, 755. 
papain, 856. 


INDEX OF DISEASES. 

Diphtheria : 

tincture of the chloride 
of iron, 477. 
muriatic acid, 482. 
subsulphate of iron, 477. 
chlorate of potassium, 

726. 

lime-water, 842. 
salicylic acid, 620. 
Diphtheritic paralysis : 

electricity, 90. 
Dislocation : 

anaesthetics, 112. 
Diuresis, excessive : 

turpentine, 735. 

Dropsy : 

diaphoretics, 746. 
antihydropin, 713. 
bitartrate of potassium, 
721. 

blisters, 806. 
caffeine, 373. 
cathartics, 676. 
eolocynth, 697. 
convallarin, 376. 
copaiba, 738. 
digitalis, 357, 711. 
elaterium, 702. 
gamboge, 703. 
hot baths, 744. 
jaborandi, 754. 
jalap, 697. 
scoparius, 712. 
senega, 768. 

spirit of nitrous ether, 
758. 

squill, 710. 
veratrine, 405. 
Drunkard’8 adynamia, 647. 

strophanthus, 378. 
Dysentery : 

acetate of lead, 455. 
cathartics, 676. 
cold, 70. 

nitrous acid, 483. 
opium, 165, 170. 
iodine, 533. 
ipecacuanha, 657. 
calomel, 686. 
castor oil, 683. 
chlorate of potassium, 

727. 

copaiba, 738. 
ergot, 794. 
flaxseed, 824. 
glycerin, 829. 
Dysmenorrhoea : 

acetate of ammonium, 
756. 

aloes, 671. 
apiol, 781. 
antipyrin, 629. 
gossypii radicis cortex, 
799. 

ginger, 645. 
belladonna, 221. 
camphor, 122. 
guaiac, 559, 782. 
nitrite of amyl, 306. 
cotton root, 799. 
Dyspepsia : 

alcohol, 343. 
antacids, 837. 


Dyspepsia : 

charcoal, 858. 
ginger, 645. 
pancreatin, 854. 
papain, 856. 
piperin, 646. 
magnesia, 679. 
pepsin, 854. 
muriatic acid, 482. 
nitrate of silver, 469. 
pepper, 646. 
nitric acid, 483. 
asafetida, 118. 
sodii carbonas, 841. 
strychnine, 264. 

Calabar bean, 272. 
taraxacum, 561. 
terebene, 777. 
wahoo, 679. 

Dyspnoea : 

strychnine, 264. 

Calabar bean, 282. 

Dysuria : 

conium, 325. 

E. 

Eczema : 

arsenic, 509. 
menthol, 607. 
ichthyol, 562. 
glycerin, 874. 
oxide of zinc ointment, 
460. 

papain, 856. 
resorcin, 610. 

Effusion, pericardial: 

iodide of potassium, 534. 
squill, 710. 

Effusion, pleural: 

iodide of potassium, 534. 
squill, 710. 

Emphysema: 

strychnine, 263. 

Empyema : 

iodine, 533. 

Endocarditis : 

mercury, 519. 

Enteritis : 

nitrate of silver, 469. 
opium, 165. 

sulphate of magnesium, 

693. 

chlorine, 868. 

. castor oil, 683. 
flaxseed, 824. 
slippery elm, 822. 

Enteritis, obstructive : 
calomel, 686. 
ulmus fulva, 822. 
flaxseed, 824. 

Ephemeral fever : 
aconite, 416. 

Epididymitis: 

nitrate of silver, 469. 

Epilepsy: 

oxide of zinc, 460. 
ammoniated copper, 461 
nitrate of silver, 469. 
antipyrin, 629. 
anaesthetics, 112. 
antifebrin, 636. 
camphor, 121. 








INDEX OF DISEASES. 


901 


Epilepsy : 

bromide of camphor, 

121 . 

ergot, 795. 

Calabar bean, 282. 
borax, 872. 

bromide of potassium, 
292. 

bromide of sodium, 296. 
bromide of lithium, 
296. 

bromide of ammonium, 
295. 

lobelia, 309. 
nitrite of amyl, 305. 
paraldehyde, 194. 
santonin, 849. 

Epistaxis: 

tannic acid, 440. 
ergot, 794. 

Epithelioma : 

resorcin, 611. 
papain, 856. 

Erysipelas : 

nitrate of silver, 468. 
benzoic acid, 773. 
borax, 871. 
ichthyol, 562. 
sulphate of iron, 475. 
tincture of the chloride 
of iron, 477. 
belladonna, 223. 
antipyrin, 629. 
quinine, 580. 
iodine, 533. 

carbolic acid injections, 
602. 

Exhaustion : 

Warburg’s tincture, 589. 
Exophthalmic goitre: 
iodine, 533. 

F. 

Ftecal accumulation : 
black draught, 692. 
Epsom salt, 693. 

Failure of heart: 
ammonia, 329. 
digitalis, 357. 

Fatty heart: 

nitrite of amyl, 306. 
Fauces, irritation of: 

acacia, 822. 

Faucitis: 

nitrate of silver, 467. 
Feeble digestion : 

feeding in, 30. 

Feet, tender : 

tannic acid, 440. 

Felon : 

nitrate of silver, 469. 
carbolic acid, 601. 

Fetid expectoration : 

carbolic acid, 763. 

Fever : 

acetphenetidin, 635. 
antipyrin, 628. 
antifebrin, 634. 
kairin, 635. 
digitalis, 360. 
thallin, 635. 
aconite, 416. 


Fever: 

cold, 59. 
chloral, 187. 
gelsemium, 314. 
muriatic acid, 482. 
nitric acid, 483. 
ammonia, 329. 
salicylic acid, 619. 
tartar emetic, 390. 
lemon-juice, 433. 
quinine, 580. 
diaphoretics, 747. 
jaborandi, 754. 

Fibroid tumors of uterus : 
ergotin, 795. 

Fissure of anus : 
belladonna, 222. 
benzoic acid, 774. 
cocaine, 250. 

Fragilitas ossium : 
phosphates, 550. 

Frost-bites : 

ichthyol, 562. 

Furuncles : 

See Boils. 

G. 

Galactorrhaea : 
ergot, 795. 

Gall-stones: 

sodium, 840. 

Gangrene: 

nitric acid, 483. 
carbolic acid, 601. 

Gangrene, hospital: 
nitric acid, 483. 
bromine, 820. 

G astralgia : 
alum, 445. 
bismuth, 458. 
manganese, 479. 
prussic acid, 527. 
arsenic, 510. 

Gastric catarrh : 

chloride of ammonium, 
767. 

papain, 856. 
bismuth, 458. 

Gastric crisis : 

antipyrin, 629. 

Gastric ulcer : 

nitrate of silver, 469. 
oil of turpentine, 735. 
resorcin, 610. 

Gastric uneasiness : 
antacids, 837. 

Gastritis : 

nitrate of silver, 469. 
veratrum viride, 397. 

Gastro-enteritis : 

chlorine water, 868. 

Glands, enlarged : 
ammoniac, 769. 
carbolic acid injections, 
601. 

conium, 325. 
iodine, 533. 
mercury, 521. 
sulphurated lime, 682. 
cod-liver oil, 546. 

Glaucoma: 

atropine, 223. 


Gleet: 

tincture of the chloride 
of iron, 497. 
thallin, 635. 
turpentine, 736. 
cantharides, 742. 

Goitre: 

iodine, 533. 

Gonorrhoea : 

acetate of zinc, 460. 
antimony, 390. 
arbutin, 729. 
thallin, 635. 
benzoic acid, 773. 
bismuth, 458. 
bromide of potassium, 
293. 

oil of sandal-wood, 731. 
nitrate of silver, 468. 
oil of erigeron, 731. 
tartar emetic, 390. 
pareira, 728. 
copaiba, 738. 
cubebs, 740. 
kawa, 742. 
matico, 741. 
quinine, 585. 
resorcin, 610. 

Gonorrhoeal rheumatism : 

salicylic acid, 619. 

Gout: 

arsenic, 510. 

carbonate of lithium, 
727. 

ether, 142. 

iodide of potassium, 535. 
ichthyol, 562. 
lithium, 727. 
magnesia, 680. 
cod-liver oil, 547. 
colchicum, 555. 
potassium, 722. 
rubefacients, 811. 
sulphuretted hydrogen, 
770. 

Gout, retrocedent: 
ether, 138. 

Granular conjunctivitis : 

sulphate of copper, 461. 
Granulations, exuberant: 
burnt alum, 444. 
sulphate of copper, 820. 
sulphate of zinc, 820. 
Gravel: 

stigmata of Indian corn, 

732. 

water, 834. 
benzoic acid, 773. 
Graves’s disease : 

iodine, 533. 

Gums, retraction of : 
iodine, 533. 

H. 

Ilsematemesis : 

tannic acid, 440. 
gallic acid, 441. 
subsulphate of iron, 476. 
oil of turpentine, 736. 
Hxmaturia : 

gallic acid, 441. 
turpentine, 736. 




902 


INDEX OF DISEASES. 


Hxmoptysis : 
alum, 444. 
acetate of lead, 455. 
gallic acid, 441. 
ipecacuanha, 658. 
subsulphate of iron, 476. 
opium, 164. 
oil of turpentine, 736. 
astringent inhalations, 
762. 

ergot, 794. 

Hay fever ; 

cocaine, 250. 
quinine, 584. 
resorcin, 610. 

Headache : 

ammonia, 330. 
antipyrin, 629. 
antacids, 837. 
caffeine, 373. 
magnesia, 693. 
ergot, 795. 

Heartburn : 

antacids, 837. 
Heart-disease : 
aconite, 416. 
adonidine, 383. 
convallaria, 376. 
digitalis, 357. 

Hoffmann’s anodyne, 
123. 

veratrum viride, 397. 
nitrite of amyl, 306. 
sparteine, 381. 
strophanthus, 378. 

Hectic fever : 

prunus Virginiana, 642. 
cold, 57. 

Hemiansesthesia , 37. 
Hemicrania : 

antipyrin, 629. 
Hemiplegia: 

electricity, 90. 
strychnine, 262. 
massage, 25. 

Hemorrhage from the bowels : 
cold, 68. 

tannic acid, 440. 
oil of turpentine, 734. 
subsulphate of iron, 476. 
Hemorrhages : 

astringents, 437. 
oil of erigeron, 731. 
oil of eucalyptus, 590. 
sulphuric acid, 480. 
matico, 741. 

subsulphate of iron, 476. 
ergot, 794. 
acetate of lead, 455. 
chlorate of potassium, 

726. 

cocaine, 250. 
Hemorrhoids : 
cocaine, 250. 
tannic acid, 440. 
stramonium, 233. 
glycerin, 830. 
iodoform, 538. 
chlorate of potassium, 

727. 

sulphur, 680. 
aloes, 690. 
cubebs, 741. 


Hemorrhoids : 
tobacco, 317. 
ergotin, 796. 

Hepatic abscess : 

chloride of ammonium, 
767. 

escharotics, 815. 

Hepatic colic : 

valerianate of amyl, 309. 
Hepatic congestion : 
nitric acid, 483. 
nitro-muriatic acid, 485. 
dandelion, 430. 
lemon-juice, 433. 
chlorine, 868. 
hydragogues, 868. 
Hepatic torpor : 

lemon-juice, 433. 
chloride of ammonium, 
767. 

potash salts, 720. 
calomel, 685. 
wahoo, 679. 
chirata, 641. 

Hepatitis : 

nitro-muriatic acid, 458. 
mercury, 519. 
chloride of ammonium, 
767. 

Hernia : 

forced enemata, 674. 
Hiccough : 

belladonna, 221. 
chloral, 187. 
ether, 142. 
musk, 115. 
oil of amber, 123. 
Hospital gangrene : 
bromine, 820. 
nitric acid, 483. 
Hydrocele : 

iodine, 533. 
carbolic acid, 602. 
Hydrocephalus : 

iodide of potassium, 
535. 

iodoform, 538. 
Hydrophobia : 

escharotics, 815. 
chlorate of potassium, 
726. 

Hypersemia , pulmonary : 

ergot, 795. 

Hypersesthesia : 

electricity in, 93. 
Hyperemesis : 

treatment, 651. 
Hyperpyrexia : 
quinine, 580. 
salicylic acid, 619. 
Hypertrophy of heart : 
digitalis, 356. 
aconite, 416. 

Hypertrophy of uterus : 

ergot, 796. 

Hypo chou dr >7< sis : 
alcohol, 342. 
electricity, 97. 

Hysteria : 

antispasmodics, 112. 
bromide of potassium, 
292. 

bromide of sodium, 296. 


Hysteria : 

brominated camphor, 

122 . 

cocaine, 251. 
musk, 115. 
valerian, 116. 
valerianic acid, 116. 
asafetida, 118. 
camphor, 121. 
conium, 320. 
electricity, 94. 
anaesthetics, 112. 
ether, 142. 

oil of wormseed, 846. 
oil of amber, 123. 
valerianate of ammo¬ 
nium, 116. 

valerianate of amyl, 309. 
Hysterical paralysis : 
electricity, 90. 

I. 

Impotence : 

turpentine, 736. 
Incontinence of urine : 
belladonna, 222. 
bromide of iron, 472. 
chloral, 187. 
strychnine, 264. 
turpentine, 736. 
Indigestion : 

charcoal, 858. 
pepsin, 854. 

Indurated glands : 

iodine, 533. 

Infantile colic : 

asafetida, 118. 

Infantile convulsions : 
anaesthetics, 112. 
asafetida, 118. 
bromide of potassium, 
292. 

brominated camphor, 

122 . 

chloral, 187. 
oil of amber, 123. 
garlic, 775. 

Infantile diarrhoea : 

phosphate of sodium, 
694. 

thymol, 609. 

Infantile paralysis : 
electricity, 89. 
massage, 25. 
strychnine, 264. 
Inflammations : 
borax, 871. 
cold, 56. 
lead, 455. 
blisters, 806. 
nitrate of silver, 469. 
tartar emetic, 390. 
mercury, 519. 
carbolic acid, 601. 
stramonium, 233. 
copaiba, 738. 
terebene, 777. 
Inflammatory fever : 

tartar emetic, 748. 
Insanity, 238. 

Intermittent fever ; 
arsenic, 507. 





INDEX OF DISEASES. 


903 


Intermittent fever : 
apiol, 781. 
chloroform, 146. 
chloride of ammonium, 
767. 

diaphoretics, 746. 
eucalyptus, 589. 
gelsemium, 313. 
ipecacuanha, 658. 
hot baths, 743. 
nitrite of amyl, 306. 
piperin, 646. 
quinine, 583. 
salicylic acid, 619. 
Intertrigo ; 

chalk, 843. 
ichthyol, 562. 

Intestinal catarrh : 

chloride of ammonium, 
767. 

cathartics, 674. 
eucalyptus, 589. 
forced enemata, 674. 
Calabar bean, 282. 
Intestinal dyspepsia : 
muriatic acid, 482. 
Calabar bean, 282. 
Intestines, inflammation of: 

slippery elm, 822. 
Intussusception : 

forced enemata, 674. 
lodism, 530. 

Iritis: 

atropine, 223. 
mercury, 519. 

Irritable bladder : 

hops, 124. 

Irritable heart: 
digitalis, 358. 
sparteine, 381. 

Irritative fevers : 

aconite, 416. 

Itch : 

sulphur, 680. 

J. 

Jaundice : 

emetics, 650. 
lemon-juice, 432. 
nitro-muriatic acid, 485. 
potassium salts, 720. 
calomel, 686. 
forced enemata, 673. 
ipecacuanha, 658. 

Joints, chronic inflammation 

of: 

blisters, 806. 
cod-liver oil, 546. 
mercurial plaster, 523. 
Joints, emlarged : 
conium, 320. 
iodine, 532. 
cod-liver oil, 546. 
emplastrum ammoniaci, 
769. 

K. 

Keloid: 

ichthyol, 562. 

Keratitis : 

atropine, 223. 


Kidneys, congestion of: 
gin, 731. 
flaxseed, 824. 

L. 

Labor: 

anaesthesia, 112. 
antipyrin, 629. 
chloroform, 146. 
ergot, 794. 

Laryngismus stridulus : 
belladonna, 221. 
chloral, 187. 

Laryngitis : 

cocaine, 250. 
diluents, 762. 
gelsemium, 314. 
glycerin, 829. 
iodol, 542. 

nitrate of silver, 467. 
narcotics, 762. 
mercury, 519. 
muriate of ammonium, 
763. 

inhalations, 763. 

Lead paralysis : 

strychnine, 262. 
electricity, 90. 
Lead-poisoning : 
atropine, 462. 
alum, 446. 
sulphuric acid, 481. 
treatment of, 447. 
strychnine, 262. 

Lepra : 

ichthyol, 562. 
Leucorrhcea : 

bismuth, 458. 
tannic acid, 440. 
ammonio-ferric alum, 
479. 

iodine, 533. 
resorcin, 610. 
permanganate of potas¬ 
sium, 867. 

Leukaemia : 
ergot, 794. 
cold, 58. 
iodoform, 538. 

Lichen : 

arsenic, 509. 

Lipoma : 

ichthyol, 562. 

Lithiasis, 51. 

Lobar pneumonia : 

quinine, 581. 

Locomotor ataxia : 
antipyrin, 629. 
nitrate of silver, 469. 
Lumbago: 

iodide of potassium, 533. 
cod-liver oil, 547. 
ichthyol, 562. 
sulphur, 681. 

Lumbrici : 

anthelmintics, 844. 
chenopodium, 846. 

Lupus : 

arsenic, 513. 
ichthyol, 562. 
phosphorus, 488. 
mercury, 519. 


Lymphoma : 

arsenic, 507. 


M. 

Malarial neuralgia : 
quinine, 582, 583. 
arsenic, 507. 

Malarial poison ing : 
chloroform, 146. 
calomel, 686. 
gelsemium, 313. 
quinine, 5K2, 583. 
arsenic, 507. 
epispastics, 806. 
bebeerine, 638. 
nectandra, 638. 
potassium salts, 720. 
apiol, 781. 
ergot, 796. 
eucalyptus, 591. 
jaborandi, 754. 
salicylic acid, 619. 
muriate of ammonia, 767. 
picric acid, 592. 
Warburg’s tincture, 588. 

Malignant pustule: 
escharotics, 815. 

Mania : 

belladonna, 223. 
bromide of potassium, 
292. 

cathartics, 676. 
chloral, 185. 
chloral camphor, 192. 
croton oil, 704. 
gelsemium, 314. 
gamboge, 703. 
hyoscine, 238. 
conium, 320. 
blisters, 806. 

Mania a potu : 

veratrum viride, 396. 
valerian, 116. 

Mastitis: 

belladonna, 226. 

Melancholia: 
alcohol, 343. 
cocaine, 251. 

Membranous croup : 
ipecac, 657. 
alum, 665. 

Meningitis: 
cold, 57. 

Menorrhagia : 
aloes, 690. 
oil of erigeron, 731. 
acetate of ammonium, 
756. 

rue, 780. 
savine, 779. 
ergot, 794. 
phosphates, 550. 
digitalis, 361. 

Menstruation, acute suppres¬ 
sion of: 

Dover’s powder, 748. 
ginger, 645. 
alcohol, 342. 
hot baths, 743. 

Mercurial sore mouth : 
tannic acid, 440. 




904 

Mercurial sore mouth: 
opium, 165. 
belladonna, 223. 

Metallic poisoning : 

iodide of potassium, 535. 
Metritis : 

ergot, 796. 

Miasmatic fever : 

diaphoretics, 746. 
Migraine : 

aconite, 417. 
antipyrin, 629. 
cannabis Indica, 201. 
nitrite of amyl, 305. 
muriate of ammonia, 
767. 

caffeine, 373. 

Mitral disease: 

digitalis, 357. 

Multiple sclerosis, 636. 
Muscular rheumatism : 
eupatorium, 641. 
ipecacuanha, 654, 
aconite, 415. 
alcohol, 344. 

Dover’s powder, 166. 
sulphur, 681. 
hot baths, 743. 
ichthyol, 562. 
iodide of potassium, 
534. 

diaphoretics, 746. 
sulphur, 680. 
salicylic acid, 619. 
Myelitis: 

electricity, 89. 
nitrate of silver, 469. 
phosphorus, 488. 

N. 

Narcotic poisoning : 
apomorphine, 664. 
ipecacuanha, 657. 
mustard, 665. 
sulphate of copper, 665. 
sulphate of zinc, 665. 
Nasal catarrh : 

eucalyptus, 589. 
Nephritis : 

belladonna, 222. 
bitartrate of potassium, 
721. 

jaborandi, 755. 

Nervous collapse : 

mustard, 665. 

Nervous cough: 

belladonna, 221. 
flaxseed, 824. 
gelsemium, 314. 

Nervous excitement: 

bromide of potassium, 
292. 

Nervous exhaustion : 
phosphorus, 488. 
Warburg’s tincture, 588. 
Nervous headache : 
caffeine, 373. 
camphor, 121. 
ether, 142. 

valerianate of ammo¬ 
nium, 117. 


INDEX OF DISEASES. 

Nervous irritability: 
asafetida, 118. 
bromide of potassium, 
292. 

prussic acid, 428. 
valerian, 116. 

Nervous vomiting : 

hydrocyanic acid, 427. 
carbolic acid, 601. 
Neuralgia : 

arsenic, 510. 
antipyrin, 629. 
bromide of potassium, 
292. 

blisters, 806. 
electricity, 93. 
phosphorus, 488. 
veratrine, 405. 
aconite, 417. 
alcohol, 343. 
valerianic acid, 117. 
gelsemium, 314. 
cannabis Indica, 201. 
belladonna, 222. 
ether, 142. 

chloral camphor, 192. 
chloroform, 150. 
croton chloral, 193. 
nitroglycerin, 309. 
iodide of potassium, 
534. 

iodoform, 538. 
cod-liver oil, 547. 
conium, 325. 
chloride of ammonium, 
767. 

valerianate of ammo¬ 
nium, 116. 
quinine, 583. 
ergot, 795. 
epispastics, 806. 
veratrine, 405. 

Neuralgia, intermittent: 
apiol, 781. 
aromatics, 648. 
arsenic, 510. 
ergot, 795. 

oil of peppermint, 648. 
quinine, 582. 

Neuralgia, intestinal: 
alum, 445. 

Neuralgia, rheumatic : 
aconite, 417. 
electricity, 93. 
iodide of potassium, 535. 
veratrine, 405. 
Neurasthenia, 40. 

cocaine, 251. 

Neuritis: 

blisters, 806. 

Night-pains, syphilitic: 

iodoform, 538. 
Night-sweats : 
alum, 665. 
belladonna, 223. 
ergot, 794. 
gallic acid, 441. 
sulphuric acid, 480. 
ipecacuanha, 654. 

Nipples, sore : 

tannic acid, 440. 

Nodes: 

ammoniac, 769. 


Nymphomania : 

bromide of potassium, 
293. 

hyoscine, 238. 


O. 

Obesity: 

saccharin, 831. 
Obstruction of the bowels : 
belladonna, 223. 
opium, 165. 

(Edema of the lungs : 

jaborandi, 754. 

CEsophagus, stricture of: 

anesthetics, 112. 
Onychia maligna : 

nitrate of lead, 4 56. 
corrosive sublimate, 819. 
Ophthalmia : 

iodine, 533. 

Opium habit: 

cocaine, 251. 
Opium-poisoning : 
caffeine, 373. 
atropine, 223. 
treatment of, 166. 
Osmidrosis : 

tannic acid, 438. 
Osteomalacia : 

phosphorus, 488. 
phosphates, 550. 

Otitis: 

resorcin, 610. 

Otorrhoea : 

permanganate of potas¬ 
sium, 867. 

Ovarian neuralgia : 
gelsemium, 314. 
muriate of ammonia, 767. 
Over-secretion : 

astringents, 437. 

Oxalic acid diathesis: 
nitric acid, 483. 
nitro-muriatic acid, 434. 
Oxyuris vermicular is : 

forced enemata, 674. 
Ozsena : 

iodine, 533. 

permanganate of potas¬ 
sium, 867. 


P. 

Pain : 

cannabis Indica, 201. 
Painful spasm : 

opium in, 164. 
Palpitation of heart: 

belladonna, 226. 
Papilloma : 

resorcin, 611. 
Paralysis : 

electricity, 90. 
massage, 25. 
strychnine, 262. 
Paralysis agitans : 
conium, 325. 
hyoscine, 238. 
Paraplegia, myelitic : 
nitrate of silver, 470. 
phosphorus, 488. 





INDEX OF DISEASES. 


905 


Parasitic skin-diseases : 
iodine, 533. 
oil of cajuput, 648. 

Parturition : 

chloroform, 150. 

Pemphigus : 

arsenic, 509. 

Pericardial effusions : 
iodoform, 538. 
blisters, 806. 
squill, 710. 

Pericarditis : 

mercury, 579. 

iodide of potassium, 535. 

iodoform, 538. 

Periostitis, syphilitic : 
phosphates, 548. 

Peripheral palsies : 
electricity, 92. 

Peritonitis : 
cold, 57. 

veratrum viride, 397. 
aconite, 416. 
opium, 165. 
mercury, 519. 
blisters, 806. 
ipecacuanha, 654. 
poultices, 833. 

Pernicious fever : 
ammonia, 330. 
epispastics, 806. 
mustard, 665. 
quinine, 583. 

Pertussis, 584. 

Phagedenic ulcers : 
nitric acid, 483. 

Phantom tumor : 

Calabar bean, 282. 

Phlegmons : 

carbolic acid injections, 
602. 

Phosphatic gravel: 
zea mays, 732. 
benzoic acid, 773. 

Phosphorus-poisoning : 
treatment of, 495. 

Phthisis: 

alcohol, 344. 
alteratives, 763. 
cannabis Indica, 201. 
cod-liver oil, 546. 
conium, 325. 
cocaine, 250. 
eucalyptus, 589. 
gallic acid, 441. 
iodine, 533. 
phosphates, 550. 
prunus Virginiana, 642. 
sulphuretted hydrogen, 
770. 

strychnine, 264. 
thymol, 609. 

Pityriasis : 

oil of cajuput, 647. 

Pleurisy : 
cold, 57. 
gelsemium, 314. 
mercury, 519. 
jaborandi, 755. 
iodide of potassium, 535. 
iodine, 533. 
blisters, 806. 
belladonna, 223. 


Pleurisy: 

poultices, 833. 

Pleuritic effusion : 
iodoform, 538. 
blisters, 806. 
squill, 710. 

Pneumonia : 

aconite, 416. 
alcohol, 342. 
antipyrin, 629. 
ammonia, 330. 
belladonna, 222. 
cold, 57. 
ergot, 795. 
expectorants, 760. 
gelsemium, 314. 
digitalis, 360. 
oil of turpentine, 736. 
tartar emetic, 390. 
musk, 115. 
chloral, 187. 
mercury, 519. 
phosphorus, 487. 
quinine, 581. 
blisters, 806. 
poultices, 833. 
veratrum viride, 397. 

Poisoning : 
heat, 55. 

Poisonous fungi, 226. 

Post-partum hemorrhage : 
ergot, 793. 
ipecacuanha, 654- 
quinine, 574. 

Pregnancy: 

confection of senna, 693. 
ipecacuanha, 657. 
phosphates, 550. 

Priapism : 
hops, 124. 

Prolapsus of rectum : 
emetics, 650. 
strychnine, 264. 

Prurigo : 

hydrocyanic acid, 428. 

Pruritus : 

chloral camphor, 192. 
glycerin, 829. 
tobacco, 317. 
menthol, 607. 

Pseudo-membranous croup : 
alum, 445. 
ipecacuanha, 654. 
mercury, 519. 
lime-water, 842. 

Psoriasis : 

resorcin, 611. 
oil of cajuput, 647. 
phosphorus, 488. 
chrysophanic acid, 585. 
arsenic, 508. 
iodine, 533. 
glycerin, 829. 

Psorophthalmia : 

yellow oxide of mercury, 
527. 

Ptyalism : 

belladonna, 223. 
opium, 165. 

Puerperal convulsions : 
nitrite of amyl, 307. 
anaesthetics, 112. 
camphor, 121. 


Puerperal convulsions: 
chloroform, 150. 
chloral, 186. 
nitroglycerin, 309. 

Puerperal fever : 

oil of turpentine, 736. 
digitalis, 357. 
borax, 871. 

Puerperal peritonitis : 
mercury, 520. 

Pulmonary oedema : 
strophanthus, 378. 

Purpura hxmorrhagica : 
oil of turpentine, 736. 
ergot, 794. 

Pyaemia : 

alcohol, 343. 

tincture of the chloride 
of iron, 477. 
quinine, 579. 

Pyelitis, chronic : 
buehu, 728. 
uva ursi, 729. 
juniper, 730. 
turpentine, 735. 
copaiba, 738. 
cantbarides, 742. 
salicylic acid, 620. 

Pyogenic membranes : 
papain, 856. 

Pyrexia : 
cold, 58. 
chloral, 188. 

Pyrosis : 

bismuth, 458. 
manganese, 479. 
nitrate of silver, 471. 
oxide of silver, 471. 

R. 

Rachitis: 

phosphorus, 488. 
phosphates, 550. 

Reaction of degeneration, 88. 

Rectum : 

feeding by, 35. 

Relaxation : 

astringents, 440. 
strychnine, 262. 

Relaxation of uvula : 
pellitory, 801. 

Remittent fever : 

diaphoretics, 746. 
quinine, 583. 
arsenic, 507. 
ipecacuanha, 658. 
Warburg’s tincture, 588. 

Renal calculi : 

belladonna, 222. 

Renal colic : 

valerianate of amyl, 309. 

Rest-cure, 40. 

Retention of urine : 
strychnine, 264. 

Retraction of gums : 
iodine, 533. 

Retrocedent gout: 
ether, 142. 

Rheumatic hyperpyrexia . 
quinine, 580. 

Rheumatic neuralgia : 
electricity, 93. 




906 

Rheumatism : 
aconite, 416. 
alcohol, 758. 
antipyrin, 629. 
arsenic, 510. 
benzoic acid, 773. 
bromide of ammonium, 
296. 

Burgundy pitch, 814. 
quinine, 580. 
jaborandi, 754. 
conium, 325. 
icbthyol, 562. 
cimicifuga, 125. 
carbolic acid injections, 
602. 

chloroform, 150. 
oil of amber, 123. 
oil of cajuput, 647. 
oil of gaultheria, 622. 
veratrine, 405. 
iodine, 534. 

iodide of potassium, 
534. 

iodoform, 538. 
cod-liver oil, 547. 
Donovan’s solution, 536. 
Dover’s powder, 748. 
colcbicum, 555. 
guaiac, 560. 
hot baths, 743. 
opium, 165. 
magnesia, 680. 
mercury, 693. 
nitrate of potassium, 
722. 

pellitory, 801. 
quinine, 581. 
salicylic acid, 619. 
Scudamore’s mixture, 
556. 

sulphur, 680. 
sulphurated potassa, 681. 
vinegar, 433. 

Rheumatism, inflammatory : 
quinine, 580. 
lemon-juice, 433. 
cimicifuga, 126. 
benzoic acid, 773. 
bromide of ammonium, 
294. 

iodide of potassium, 535. 
potassium salts, 713. 
nitrate of potassium, 722. 
salol, 624. 
salicin, 623. 
salicylic acid, 619. 
oil of gaultheria, 619. 
Dover’s powder, 748. 
vinegar, 433. 
acetate of potassium, 
720. 

Rheumatoid arthritis : 
arsenic. 510. 

iodide of potassium, 535. 
Rhus toxicodendron poison- 
iny : 

lobeiia, 309. 

Rickets : 

phosphorus, 488. 
cod-liver oil, 546. 
Rigidity of os uteri : 
belladonna, 222. 


INDEX OF DISEASES. 

Round-icorms : 

anthelmintics, 844. 
oil of turpentine, 732, 
851. 

spigelia, 845. 
azedarach, 845. 
chenopodium, 845. 
santonin, 850. 
mucuna, 852. 

S. 

Scabies : 

glycerin, 829. 

Scarlet fever : 
aconite, 416. 
antipyrin, 629. 
belladonna, 223. 
cold, 69. 

chlorate of potassium, 
730. 

quinine, 579. 

Sciatica : 

conium, 325. 
iodide of potassium, 533. 
cod-liver oil, 547. 
sulphur, 681. 
electricity, 93. 

Sclerosis : 

antifebrin, 636. 

Scrof ulosis: 

alcohol, 344. 
sarsaparilla, 559. 
pipsissewa, 730. 
iodine, 532. 
cod-liver oil, 545. 
phosphoric acid, 548. 
phosphates, 550. 
syrup of iodide of iron, 
477. 

Scrofulous tumors : 

emplastrum ammoniaci, 
769. 

Scrofulous ulcers : 

sulphurated lime, 682. 
Scurvy: 

lemon-juice, 432. 
chlorate of potassium, 
726. 

vinegar, 433. 

Seat-worms : 

anthelmintics, 844. 
forced enemata, 764. 
quassia, 637. 
oil of cajuput, 647. 
vinegar, 434. 

Seborrhcea : 

glycerin, 829. 

Septicaemia : 

quinine, 579. 
borax, 871. 

Serous diarrhoea : 
cold, 69. 

Sexxtal excitement: 

bromide of potassium, 
292. 

camphor, 121. 
hyoscine, 238. 
hops, 124. 

Shock : 

belladonna, 223. 
epispastics, 805. 
ergot, 895. 


Shock : 

hot baths, 55. 

Sick headache : 
antacids, 838. 
magnesia, 693. 

Sick stomach : 

ipecacuanha, 654. 

Singultus: 

chloral, 187. 

Sinking-spells: 
ether, 142. 

Skin, affections of : 
arsenic, 507. 
chalk, 843. 
cod-liver oil, 547. 
Donovan’s solution, 536. 
ichthyol, 561. 
magnesia, 680. 
nitro-muriatic acid, 4S5. 
tar, 776. 

oxide of mercury, 527. 
copaiba, 739. 
oxide of zinc, 460. 
sulphur, 680. 
sulphurated potassa, 671. 

Sleeplessness : 
opium, 164. 
cannabis Indica, 201. 
chloral, 185. 

bromide of potassium, 
292. 

hyoscine, 236. 
acetophenone, 196. 
amylene hydrate, 194. 
urethan, 195. 
bypnone, 196. 

Smallpox : 

opium, 165. 
ichthyol, 562. 

Snake-poisoning: 
ammonia, 329. 
alcohol, 343. 
epispastics, 806. 

Softening of brain : 
phosphorus, 488. 

Sore throat: 
alum, 444. 
chlorine-water, 868. 
nitrate of silver, 468. 
belladonna, 223. 
chlorate of potassium, 
724. 

sumach berries, 443. 
gum arabic, 822. 
carbolic acid, 601. 
tannic acid, 440. 

Spasms : 

atropine, 223. 
tobacco, 319. 
opium, 165. 
asafetida, 118. 
hyoscine, 239. 
oil of cajuput, 647. 
aconite, 416. 
belladonna, 221. 
chloral, 186. 
anaesthetics, 112. 

Sp>ermatorrhcea : 

brominated camphor, 

122 . 

digitalis, 361. 
chloral, 375. 
hyoscine, 238. 




INDEX OF DISEASES. 


907 


Spermatorrhoea : 

turpentine, 736. 

Spinal accessory spasm, 194. 
Spinal anmmia or irritation : 

electricity, 96. 

Spinal congestion : 
electricity, 96. 
ergot, 795. 

Spinal depression: 

strychnine, 256. 

Spinal inflammation, 96. 
Spleen, enlargement of: 

bromide of potassium, 
285. 

cold, 57. 
ergot, 794. 

Spongy gums : 

tannic acid, 440. 

Sprain8 : 

arnica, 4@6. 
camphor, 121. 

Goulard’s extract, 455. 
ichthyol, 562. 
massage, 25. 
vinegar, 434. 

Status epilepticus : 

nitrite of amyl, 305. 
Stomatitis : 

chlorate of potassium, 
726. 

carbolic acid, 601. 
Strangury : 

opium, 170. 

Stricture, spasmodic: 
anaesthetics, 112. 
belladonna, 222. 
Strychnine-poisoning : 
treatment of, 258. 
Calabar bean, 282. 
bromide of potassium, 
293. 

chloral, 187. 
nitrite of amyl, 307. 
tobacco, 319. 
Subinvolution of uterus: 
ergot, 796. 

Suffocative catarrh, 664. 
Sunburn : 

vinegar, 434. 

Suppressed menstruation ; 
ginger, 645. 
diaphoretics, 746. 

Dover’s powder, 748. 
alcohol, 758. 

Suppression of urine : 

digitalis, 711. 

Sweating, excessive : 
gallic acid, 441. 
chalk, 843. 
jaborandi, 754. 
sulphuric acid, 842. 
Syncope: 

ammonia, 329. 
alcohol, 343. 
digitalis, 357. 
ether, 138. 
nitrite of amyl, 306. 
Synovitis, chronic: 

carbolic acid injections, 
602. 

Syphilis: 

nitric acid, 483. 
nitro-muriatic acid, 485. 


Syphilis: 

mercury, 521, 527. 
iodide of potassium, 535. 
iodoform, 538. 
sulphur, 681. 
cod-liver oil, 547. 
sarsaparilla, 559. 
guaiac, 559. 

chlorate of potassium, 
726. 

phosphates, 550. 
Syphilitic nodes : 

emplastrum ammoniaci 
cum hydrargyro, 769. 


T. 

Tabes mesenterica : 

cod-liver oil, 546. 

Tsenise : 

anthelmintics, 844. 
Tape-worm : 

anthelmintics, 844. 
ether, 142. 
forced enemata, 674. 
chenopodium, 846. 
chloroform, 150. 
brayera, 846. 
kamala, 852. 
pepo, 851. 
picric acid, 593. 
rottlera, 852. 
male fern, 851. 
mucuna, 852. 
pomegranate, 851. 
turpentine, 735, 851. 
Teething : 

brominated camphor, 121. 
Tetanus : 

cannabis Indica, 201. 
Calabar bean, 281. 
bromide of potassium, 
292. 

chloral, 186. 
lobelia, 309. 
nitrite of amyl, 306. 
tobacco, 319. 
urethan, 195. 
Tic-douloureux : 

croton chloral, 193. 
gelsemium, 311. 

Tinea capitis : 

lime-water, 842. 
Tonsillitis : 

tincture of capsicum, 
647. 

Toothache : 

chloral camphor, 192. 
oil of cloves, 644. 
pellitory, 801. 
Trichiniasis : 

picric acid, 593. 

Trismus nascentium : 

Calabar bean, 281. 
chloral, 187. 

Tubercular laryngitis : 

iodol, 541. 

Tuberculosis : 

cod-liver oil, 547. 
Tuberculous diarrhoea, 657. 
Tumors: 

escharotics, 815. 


Tumors : 

emplastrum ammoniaci 
cum hydrargyro, 769. 

Tympanitis : 

asafetida, 118. 
aromatics, 643. 

Typhoid fever : 
quinine, 580. 
alcohol, 342. 
cold, 64. 
jaborandi, 754. 
oil of turpentine, 735. 
digitalis, 361. 
veratrum viride, 396. 
salicylic acid, 622. 
salol, 624. 
mineral acids, 480. 
musk, 115. 
thymol, 609. 
antipyrin, 629. 

Typhoid pneumonia : 
phosphorus, 487. 

Typhus fever: 
alcohol, 342. 
antipyrin, 629. 
belladonna, 223. 
chloral, 185. 
chlorine-water, 868. 
cold, 64. 

salicylic acid, 620. 
digitalis, 361. 
quinine, 580. 


U. 

Ulcer of cervix uteri : 

solution of nitrate of 
mercury, 819. 

Ulcer of cornea : 
atropine, 223. 

Ulceration, chronic : 
conium, 320. 
iodoform, 538. 

Ulceration of the bowels : 
oil of turpentine, 735. 

Ulcers : 

alum, 444. 
bismuth, 458. 
borax, 871. 
carbolic acid, 601. 
chloride of zinc, 818. 
conium, 320, 325. 
chloral, 185. 
chlorine, S68. 
chalk, 843. 
charcoal, 858. 
escharotics, 815. 
iodoform, 538. 
nitrate of mercury, 819. 
nitrate of silver, 467. 
nitric acid, 482, 819. 
sulphuric acid, 480. 
sulphate of copper, 461. 
oxide of zinc, 460. 
tannic acid, 440. 
lime-water, 842. 
chlorine-water, 868. 
cocaine, 250. 
cold, 57. 

permanganate of potas¬ 
sium, 867. 







908 

Unilateral sweating : 

jaborandi, 755. 

Ununited fracture : 

phosphates, 548. 

Uraemia: 

chloral, 185. 
opium, 165. 
elaterium, 702. 
jaborandi, 754. 
nitroglycerin, 309. 
Uraemic convulsions : 

chloral, 186. 

Urethral fever : . 

aconite, 416. 
bromide of potassium, 
292. 

Urethral spasm : 

belladonna, 222. 
Urethritis : 

nitrate of silver, 467. 
Uric acid calculus and 
gravel: 

benzoic acid, 773. 
potassium salts, 720. 
sodium salts, 841. 
zea mays, 732. 

Uric acid diathesis : 
benzoic acid, 773. 
carbonate of lithium, 
727. 

potassium salts, 720. 
sodium salts, 841. 
Urticaria : 

arsenic, 509. 
ichthyol, 562. 
emetics, 650. 
menthol, 607. 

Uterine inertia : 
ergot, 792. 

smut of Indian corn, 
799. 

Uterus, cancer of: 

Chian turpentine, 736. 
chloral, 188. 
iodoform, 541. 

Uterus, subinvolution of: 
ergot, 792. 


INDEX OF DISEASES. 

Uvula, relaxation of: 
pellitory, 801. 

V. 

Vaginal catarrh : 

iodol, 542. 

Vaginismus : 

piperin, 646. 

Vaginitis : 

grindelia, 765. 

Valvular disease of heart : 
digitalis, 357. 
aconite, 416. 
veratrum viride, 397. 
compound spirit of ether, 
124. 

convallaria majalis, 376. 
Venereal ulcers : 

Canquoin’s paste in, 818. 
sulphuric acid, 480. 
Venereal warts : 

nitric acid, 483. 

Veratrum viride poisoning : 

alcohol, 343. * 

Vesical catarrh : 

benzoic acid, 773. 
thymol, 609. 

Vomiting: 

aconite, 417. 
bismuth, 458. 
cocaine, 251. 
ipecacuanha, 657. 
prussic acid, 427. 
opium, 165, 170. 
oxalate of cerium, 459. 
lime-water, 842. 
carbolic acid, 601. 
Vomiting, excessive: 

treatment of, 651. 
Vomiting of pregnancy : 
aconite, 417. 

bromide of potassium, 
292. 

ipecacuanha, 657. 
oxalate of cerium, 459. 


Vomiting of pregnancy : 
resorcin, 610. 

W. 

Warts: 

nitric acid, 483. 
papain, 856. 

White swelling : 

cod-liver oil, 546. 
Whooping-cough : 
asafetida, 118. 
camphor, 121. 
belladonna, 222. 
hyoscine, 238. 
gelsemium, 314. 
bromide of ammonium, 
296. 

chloral, 187. 
conium, 325. 
arsenic, 510. 
resorcin, 610. 
lobelia, 311. 
quinine, 584. 
grindelia, 765. 
ergot, 795. 
oil of amber, 123. 

Winter cough : 

strychnine, 264. 
terebene, 776. 

Worms : 

ether, 142. 
picric acid, 593. 
forced enemata, 674. 
Wounds: 

alcohol dressing, 344. 
carbolic acid, 601. 
salicylic acid, 621. 
carbolated camphor, 122. 
charcoal, S58. 
escharotics, 815. 
permanganate of potas¬ 
sium, 867. 

Y. 

Yellow fever : 

antipyrin, 629. 


THE END. 




NERVOUS DISEASES 

AND THEIR DIAGNOSIS. 


By II. C. WOOD, M.D., LL.D. 


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